Provider Demographics
NPI:1285957761
Name:PROVIDENT ARC LLC
Entity type:Organization
Organization Name:PROVIDENT ARC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:REYNALDO
Authorized Official - Middle Name:
Authorized Official - Last Name:ROUNDTREE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-861-4409
Mailing Address - Street 1:17300 RIVER RIDGE BLVD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-5167
Mailing Address - Country:US
Mailing Address - Phone:703-861-4409
Mailing Address - Fax:
Practice Address - Street 1:17300 RIVER RIDGE BLVD
Practice Address - Street 2:SUITE 301
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-5167
Practice Address - Country:US
Practice Address - Phone:703-861-4409
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-11
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA954320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities