Basic Information
| Provider Information | |||||||||
| NPI: | 1447335179 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE LAURELS OF CHARLOTTESVILLE, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE LAURELS OF CHARLOTTESVILLE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1165 PEPSI PL | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTESVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229012866 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4349514200 | ||||||||
| FaxNumber: | 4349514201 | ||||||||
| Practice Location | |||||||||
| Address1: | 1165 PEPSI PL | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTESVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229012866 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4349514200 | ||||||||
| FaxNumber: | 4349514201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2006 | ||||||||
| LastUpdateDate: | 10/05/2007 | ||||||||
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| AuthorizedOfficialLastName: | PATTON | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6147948800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BP3500X | NH2754 | VA | Y | Suppliers | Durable Medical Equipment & Medical Supplies | Parenteral & Enteral Nutrition |
ID Information
| ID | Type | State | Issuer | Description | 7105596 | 01 | VA | UNITED HEALTH CARE ID # | OTHER | 147664 | 01 | VA | BC/BS # | OTHER | NH2754 | 01 | VA | NH LICENSE # | OTHER |