MEDICARE: GERTRUDE HOMES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility	2121	VA

General Provider Information

NPI Number	:	1073069399
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GERTRUDE HOMES LLC

Provider Business Mailing Address
First Line	:	7566 QUAKER DRIVE
Second Line	:
City	:	SUFFOLK
State	:	VA
Zip	:	23437-8906
Country	:	US
Telephone Number	:	757-567-0923
Fax Number	:

Provider Business Practice Location Address
First Line	:	7566 QUAKER DR
Second Line	:
City	:	SUFFOLK
State	:	VA
Zip	:	23437-8906
Country	:	US
Telephone Number	:	757-567-0923
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	CLARENCE RUSSELL JR.
Credential	:
Telephone Number	:	757-567-0923

Provider Enumeration Date	:	08/28/2016
Last Update Date	:	08/28/2016

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Directions to “GERTRUDE HOMES LLC ” Practice Location

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