MEDICARE: DIVERSITY RESIDENTIAL HOMES

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	70201001	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	70201001	OTHER	VA	DMHMRSAS PROVIDER #

General Provider Information

NPI Number	:	1811046311
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVERSITY RESIDENTIAL HOMES

Provider Business Mailing Address
First Line	:	PO BOX 74425
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23236-0008
Country	:	US
Telephone Number	:	804-405-4000
Fax Number	:	804-743-1845

Provider Business Practice Location Address
First Line	:	5216 BAYVIEW DR
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23234-4504
Country	:	US
Telephone Number	:	804-405-4000
Fax Number	:	804-743-1845

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MICHELLE WHITTINGHAM
Credential	:	M.ED.
Telephone Number	:	804-405-4000

Provider Enumeration Date	:	01/10/2007
Last Update Date	:	08/22/2020

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Directions to “DIVERSITY RESIDENTIAL HOMES ” Practice Location

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