MEDICARE: TRI-CITIES ADULT SERVICES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number State
1	251S00000X	Community/Behavioral Health Agency	VA
2	385H00000X	Respite Care	VA
3	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility	VA

General Provider Information

NPI Number	:	1356848055
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRI-CITIES ADULT SERVICES LLC

Provider Business Mailing Address
First Line	:	6220 SKEET RD
Second Line	:
City	:	SUFFOLK
State	:	VA
Zip	:	23435-2604
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	145 LEE ST UNIT A
Second Line	:
City	:	SUFFOLK
State	:	VA
Zip	:	23434-5346
Country	:	US
Telephone Number	:	757-822-0785
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	PRINCESS BARNES
Credential	:
Telephone Number	:	757-822-0785

Provider Enumeration Date	:	04/09/2018
Last Update Date	:	04/09/2018

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