MEDICARE: ROANENTEPRISES, 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	103TP2701X	Group Psychotherapy Psychologist

General Provider Information

NPI Number	:	1740412071
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROANENTEPRISES, LLC

Provider Business Mailing Address
First Line	:	PO BOX 322
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23218-0322
Country	:	US
Telephone Number	:	804-213-0540
Fax Number	:	804-213-0542

Provider Business Practice Location Address
First Line	:	3122 W CLAY ST
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23230-4728
Country	:	US
Telephone Number	:	804-213-0540
Fax Number	:	804-213-0542

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	MR. MARVIN VAN ROANE
Credential	:
Telephone Number	:	804-349-6382

Provider Enumeration Date	:	08/20/2009
Last Update Date	:	08/20/2009

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