MEDICARE: IMMACULATE CARE RESIDENTIAL SERVICES 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

General Provider Information

NPI Number	:	1598235731
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMMACULATE CARE RESIDENTIAL SERVICES LLC

Provider Business Mailing Address
First Line	:	5935 KNIGHTSBRIDGE WAY
Second Line	:
City	:	PORTSMOUTH
State	:	VA
Zip	:	23703-5506
Country	:	US
Telephone Number	:	757-335-2404
Fax Number	:

Provider Business Practice Location Address
First Line	:	5935 KNIGHTSBRIDGE WAY
Second Line	:
City	:	PORTSMOUTH
State	:	VA
Zip	:	23703-5506
Country	:	US
Telephone Number	:	757-335-2404
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MINNIE SVAGE
Credential	:	MA. ED
Telephone Number	:	757-335-2404

Provider Enumeration Date	:	11/30/2018
Last Update Date	:	08/04/2022

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