MEDICARE: SHANGRI-LA, 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	2473	VA

General Provider Information

NPI Number	:	1902299985
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHANGRI-LA, LLC

Provider Business Mailing Address
First Line	:	PO BOX 1014
Second Line	:
City	:	PRINCE GEORGE
State	:	VA
Zip	:	23875-0961
Country	:	US
Telephone Number	:	804-541-3589
Fax Number	:

Provider Business Practice Location Address
First Line	:	3650 BUTOR RD
Second Line	:
City	:	NORTH PRINCE GEORGE
State	:	VA
Zip	:	23860-7429
Country	:	US
Telephone Number	:	804-541-3589
Fax Number	:

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	MS. LORETTA FAULKNIER
Credential	:
Telephone Number	:	804-541-3589

Provider Enumeration Date	:	03/14/2015
Last Update Date	:	03/14/2015

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