MEDICARE: LOUISE W. EGGLESTON CENTER

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	251C00000X	Developmentally Disabled Services Day Training Agency	16702006	VA
2	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility	16701001	VA

General Provider Information

NPI Number	:	1093768921
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LOUISE W. EGGLESTON CENTER

Provider Business Mailing Address
First Line	:	1161 INGLESIDE RD
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23502-5608
Country	:	US
Telephone Number	:	757-858-8011
Fax Number	:	757-627-4760

Provider Business Practice Location Address
First Line	:	6431 TIDEWATER DR
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23509-1600
Country	:	US
Telephone Number	:	757-858-8011
Fax Number	:	757-858-8057

Authorized Official
Title or Position	:	CHIEF OPERATING OFFICER
Name	:	MR. DAVE WILBER
Credential	:
Telephone Number	:	757-858-8011

Provider Enumeration Date	:	05/19/2006
Last Update Date	:	09/11/2025

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