MEDICARE: FREEMAN HOUSE, 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	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1336318179
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FREEMAN HOUSE, INC

Provider Business Mailing Address
First Line	:	2909 E VIRGINIA BEACH BLVD
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23504
Country	:	US
Telephone Number	:	757-622-1603
Fax Number	:	757-622-0758

Provider Business Practice Location Address
First Line	:	2909 E VIRGINIA BEACH BLVD
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23504
Country	:	US
Telephone Number	:	757-622-1603
Fax Number	:	757-622-0758

Authorized Official
Title or Position	:	CHIEF ADMINISTRATIVE OFFICER
Name	:	MS. KHALILAH M SHABAZZ
Credential	:
Telephone Number	:	757-622-1603

Provider Enumeration Date	:	02/26/2008
Last Update Date	:	09/11/2008

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