MEDICARE: INTREPID OF VIRGINIA, INC.

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	251G00000X	Community Based Hospice Care Agency	HSP-16232	VA

General Provider Information

NPI Number	:	1184174864
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTREPID OF VIRGINIA, INC.

Provider Business Mailing Address
First Line	:	14841 DALLAS PKWY STE 625
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75254-7641
Country	:	US
Telephone Number	:	214-445-3750
Fax Number	:	214-445-3994

Provider Business Practice Location Address
First Line	:	165 MARKET ST STE 2
Second Line	:
City	:	ONANCOCK
State	:	VA
Zip	:	23417-4233
Country	:	US
Telephone Number	:	757-356-4182
Fax Number	:	757-787-8430

Authorized Official
Title or Position	:	CCO
Name	:	ROBERT PARKER
Credential	:
Telephone Number	:	214-445-3750

Provider Enumeration Date	:	10/06/2016
Last Update Date	:	11/09/2022

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