MEDICARE: WE CARE RESIDENTIAL, 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	:	1962637678
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WE CARE RESIDENTIAL, LLC

Provider Business Mailing Address
First Line	:	108 STERLING FOREST PKWY
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23227-1677
Country	:	US
Telephone Number	:	804-523-7702
Fax Number	:	866-383-5281

Provider Business Practice Location Address
First Line	:	2317 WESTWOOD AVE
Second Line	:	SUITE 209
City	:	RICHMOND
State	:	VA
Zip	:	23230-4007
Country	:	US
Telephone Number	:	804-523-7702
Fax Number	:	866-383-5281

Authorized Official
Title or Position	:	CEO/OWNER
Name	:	MR. DARYL A JEFFERSON
Credential	:
Telephone Number	:	804-523-7702

Provider Enumeration Date	:	05/26/2009
Last Update Date	:	05/26/2009

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