MEDICARE: NAOMI'S PLACE, 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	251B00000X	Case Management Agency
2	251S00000X	Community/Behavioral Health Agency	4071	VA

General Provider Information

NPI Number	:	1790931509
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NAOMI'S PLACE, LLC

Provider Business Mailing Address
First Line	:	5500 BARNSLEY TER
Second Line	:
City	:	GLEN ALLEN
State	:	VA
Zip	:	23059-3424
Country	:	US
Telephone Number	:	804-833-6036
Fax Number	:	804-360-0660

Provider Business Practice Location Address
First Line	:	4512 SADLER GROVE CT
Second Line	:
City	:	GLEN ALLEN
State	:	VA
Zip	:	23060-6181
Country	:	US
Telephone Number	:	804-833-6036
Fax Number	:	804-360-0660

Authorized Official
Title or Position	:	OWNER
Name	:	NAOMI WALKER
Credential	:
Telephone Number	:	804-833-6036

Provider Enumeration Date	:	08/12/2008
Last Update Date	:	08/12/2008

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