MEDICARE: INNER-VISION EDUCATION CENTER, 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	199102006	VA

General Provider Information

NPI Number	:	1326462334
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INNER-VISION EDUCATION CENTER, LLC

Provider Business Mailing Address
First Line	:	1572 STANDING RIDGE DR
Second Line	:
City	:	POWHATAN
State	:	VA
Zip	:	23139-8051
Country	:	US
Telephone Number	:	804-794-1573
Fax Number	:	804-414-7026

Provider Business Practice Location Address
First Line	:	1572 STANDING RIDGE DR
Second Line	:
City	:	POWHATAN
State	:	VA
Zip	:	23139-8051
Country	:	US
Telephone Number	:	804-794-1573
Fax Number	:	804-414-7026

Authorized Official
Title or Position	:	OWNER
Name	:	DAMON PETERSON
Credential	:
Telephone Number	:	804-794-1573

Provider Enumeration Date	:	02/11/2014
Last Update Date	:	02/11/2014

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