Basic Information
| Provider Information | |||||||||
| NPI: | 1124512637 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INNOVAGE VIRGINIA PACE II, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | INNOVAGE VIRGINA PACE-PENINSULA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8950 E LOWRY BLVD | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802307030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3038694664 | ||||||||
| FaxNumber: | 3039961600 | ||||||||
| Practice Location | |||||||||
| Address1: | 1300 MACTAVISH AVE | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232304633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8049775990 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2018 | ||||||||
| LastUpdateDate: | 06/18/2018 | ||||||||
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| AuthorizedOfficialLastName: | HEWITT | ||||||||
| AuthorizedOfficialFirstName: | MAUREEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3038694664 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | TOTAL COMMUNITY OPTIONS INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251T00000X | VA | Y | Agencies | PACE Provider Organization |
No ID Information.