MEDICARE: SENTARA LIFE CARE CORPORATION

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	311Z00000X	Custodial Care Facility	ELO 2004-399	VA

General Provider Information

NPI Number	:	1326039546
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SENTARA LIFE CARE CORPORATION

Provider Business Mailing Address
First Line	:	251 S NEWTOWN RD
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23502-5718
Country	:	US
Telephone Number	:	757-892-5400
Fax Number	:	757-892-5401

Provider Business Practice Location Address
First Line	:	3751 SENTARA WAY
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23452-4200
Country	:	US
Telephone Number	:	757-306-2850
Fax Number	:	757-306-2801

Authorized Official
Title or Position	:	VICE PRESIDENT SENTARA LIFE CARE
Name	:	BRUCE ROBERTSON
Credential	:
Telephone Number	:	757-892-5400

Provider Enumeration Date	:	11/04/2005
Last Update Date	:	04/08/2008

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