Basic Information
| Provider Information | |||||||||
| NPI: | 1306836655 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALBEMARLE LIFECARE CORP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | HERITAGE HALL CHARLOTTESVILLE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 505 RIO RD W | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTESVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229011411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4349787015 | ||||||||
| FaxNumber: | 4349747882 | ||||||||
| Practice Location | |||||||||
| Address1: | 505 RIO RD W | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTESVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229011411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4349787015 | ||||||||
| FaxNumber: | 4349747882 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LENEAVE | ||||||||
| AuthorizedOfficialFirstName: | TED | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/COO | ||||||||
| AuthorizedOfficialTelephone: | 5407744263 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | NH2572 | VA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 227277 | 01 | VA | ANTHEM BCBS PPO HMO ID | OTHER | 4951786 | 05 | VA | MEDICAID | 153707 | 01 | VA | SOUTHERN HEALTH SVCS ID | OTHER |