MEDICARE: PROVINCE PLACE

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	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1295998458
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROVINCE PLACE

Provider Business Mailing Address
First Line	:	6403 GRANBY ST
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23505-4447
Country	:	US
Telephone Number	:	757-451-2400
Fax Number	:

Provider Business Practice Location Address
First Line	:	6403 GRANBY ST
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23505-4447
Country	:	US
Telephone Number	:	757-451-2400
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MS. MARJ PANTONE
Credential	:
Telephone Number	:	757-451-2400

Provider Enumeration Date	:	07/08/2008
Last Update Date	:	07/08/2008

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Directions to “PROVINCE PLACE ” Practice Location

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