Provider Demographics
NPI:1194759100
Name:OLIVIA'S GROUP HOME LONCHMNS, INC.
Entity type:Organization
Organization Name:OLIVIA'S GROUP HOME LONCHMNS, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:LILLIAN
Authorized Official - Middle Name:JACQUELINE
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:M ED
Authorized Official - Phone:804-266-3897
Mailing Address - Street 1:7501 MOSS SIDE AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23227-1837
Mailing Address - Country:US
Mailing Address - Phone:804-266-3897
Mailing Address - Fax:804-264-1510
Practice Address - Street 1:7501 MOSS SIDE AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23227-1837
Practice Address - Country:US
Practice Address - Phone:804-266-3897
Practice Address - Fax:804-264-1510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA531320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA=========OtherEMPLOYER IDENTIFICATION #