MEDICARE: KIDS KIN N CAREGIVERS

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	251V00000X	Voluntary or Charitable Agency

General Provider Information

NPI Number	:	1477079408
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIDS KIN N CAREGIVERS

Provider Business Mailing Address
First Line	:	2085 LYNNHAVEN PKWY STE 106-315
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23456-1497
Country	:	US
Telephone Number	:	757-434-5162
Fax Number	:

Provider Business Practice Location Address
First Line	:	6300 E VIRGINIA BEACH BLVD
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23502-2827
Country	:	US
Telephone Number	:	757-434-5162
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	DR. KATHY L DIAL
Credential	:	PHD
Telephone Number	:	757-434-5162

Provider Enumeration Date	:	08/22/2017
Last Update Date	:	08/22/2017

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