MEDICARE: HALO, INC.

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	523-01	VA

General Provider Information

NPI Number	:	1982677027
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HALO, INC.

Provider Business Mailing Address
First Line	:	1857A FORT MAHONE ST
Second Line	:	P. O. BOX 28
City	:	PETERSBURG
State	:	VA
Zip	:	23805-2761
Country	:	US
Telephone Number	:	804-733-9140
Fax Number	:	804-733-9216

Provider Business Practice Location Address
First Line	:	1857A FORT MAHONE ST
Second Line	:
City	:	PETERSBURG
State	:	VA
Zip	:	23805-2761
Country	:	US
Telephone Number	:	804-733-9140
Fax Number	:	804-733-9216

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. HARRY LEGROS
Credential	:	QMRP/QMHP
Telephone Number	:	804-733-9140

Provider Enumeration Date	:	02/09/2006
Last Update Date	:	08/22/2020

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