Provider Demographics
NPI:1063609659
Name:ANNZETTA'S THERAPEUTIC HOME FOR BOYS, LLC
Entity type:Organization
Organization Name:ANNZETTA'S THERAPEUTIC HOME FOR BOYS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE CLERK
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:EMMA
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-861-5182
Mailing Address - Street 1:1834 BUCKNER ST
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23805-1705
Mailing Address - Country:US
Mailing Address - Phone:804-863-2661
Mailing Address - Fax:
Practice Address - Street 1:1834 BUCKNER ST
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23805-1705
Practice Address - Country:US
Practice Address - Phone:804-863-2661
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-27
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness