Basic Information
Provider Information | |||||||||
NPI: | 1669809109 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | AL CHESTERFIELD OPERATIONS, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ELMCROFT OF CHESTERFIELD | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 9510 ORMSBY STATION RD | ||||||||
Address2: | SUITE 101 | ||||||||
City: | LOUISVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 402234081 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5027536004 | ||||||||
FaxNumber: | 5027536104 | ||||||||
Practice Location | |||||||||
Address1: | 1000 TWINRIDGE LN | ||||||||
Address2: |   | ||||||||
City: | NORTH CHESTERFIELD | ||||||||
State: | VA | ||||||||
PostalCode: | 232355248 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8043271990 | ||||||||
FaxNumber: | 8043272449 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/30/2013 | ||||||||
LastUpdateDate: | 09/30/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BARBER | ||||||||
AuthorizedOfficialFirstName: | ROBIN | ||||||||
AuthorizedOfficialMiddleName: | L. | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 5027536004 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | JD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | CLO-08-1103961 | VA | Y |   | Nursing & Custodial Care Facilities | Assisted Living Facility |   |
ID Information
ID | Type | State | Issuer | Description | CLO-08-1103961 | 01 | VA | RESIDENTIAL CARE AND ASSISTED LIVING CARE LICENSE | OTHER |