Provider Demographics
NPI:1215260492
Name:G&G RESPITE SERVICES
Entity type:Organization
Organization Name:G&G RESPITE SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:REHAB.SPECIALIST
Authorized Official - Prefix:MS
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:VUMAH
Authorized Official - Last Name:MBENGABONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-973-8821
Mailing Address - Street 1:2810 BURROUGH HILL LN
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-5155
Mailing Address - Country:US
Mailing Address - Phone:703-973-8821
Mailing Address - Fax:703-796-9615
Practice Address - Street 1:2810 BURROUGH HILL LN
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-5155
Practice Address - Country:US
Practice Address - Phone:703-973-8821
Practice Address - Fax:703-796-9615
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:G&G RESPITE SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-09-06
Last Update Date:2009-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QD1600X, 385HR2060X
DC261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC=========Medicaid