MEDICARE: RESIDENTIAL LIVING OPTIONS 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	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility	725-01-001	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1447352042
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RESIDENTIAL LIVING OPTIONS LLC

Provider Business Mailing Address
First Line	:	1013 SAINT ANDREWS WAY APT C
Second Line	:
City	:	CHESAPEAKE
State	:	VA
Zip	:	23320-8524
Country	:	US
Telephone Number	:	757-410-0229
Fax Number	:

Provider Business Practice Location Address
First Line	:	3314 LENS AVE
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23509-2610
Country	:	US
Telephone Number	:	757-855-3782
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	DR. GREGORY LYDELL SMITH
Credential	:	PH.D
Telephone Number	:	757-477-1221

Provider Enumeration Date	:	09/02/2006
Last Update Date	:	10/07/2008

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Directions to “RESIDENTIAL LIVING OPTIONS LLC ” Practice Location

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