MEDICARE: SANDY HOUSE, 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		VA

General Provider Information

NPI Number	:	1255509675
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SANDY HOUSE, LLC

Provider Business Mailing Address
First Line	:	2317 WESTWOOD AVE
Second Line	:	SUITE 209
City	:	RICHMOND
State	:	VA
Zip	:	23230-4007
Country	:	US
Telephone Number	:	804-523-7702
Fax Number	:

Provider Business Practice Location Address
First Line	:	2317 WESTWOOD AVE
Second Line	:	SUITE 209
City	:	RICHMOND
State	:	VA
Zip	:	23230-4007
Country	:	US
Telephone Number	:	804-523-7702
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	MS. AISHA J BULLARD
Credential	:
Telephone Number	:	804-523-7702

Provider Enumeration Date	:	02/19/2008
Last Update Date	:	02/19/2008

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