Provider Demographics
NPI:1396768644
Name:VIDELL HEALTHCARE DUFFIELD LLC
Entity type:Organization
Organization Name:VIDELL HEALTHCARE DUFFIELD LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXEC VICE PRES
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:D
Authorized Official - Last Name:MACE
Authorized Official - Suffix:
Authorized Official - Credentials:RN DCS
Authorized Official - Phone:253-277-3197
Mailing Address - Street 1:157 ROSS CARTER BLVD
Mailing Address - Street 2:
Mailing Address - City:DUFFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:24244-0280
Mailing Address - Country:US
Mailing Address - Phone:276-431-2841
Mailing Address - Fax:276-431-4718
Practice Address - Street 1:157 ROSS CARTER BLVD
Practice Address - Street 2:
Practice Address - City:DUFFIELD
Practice Address - State:VA
Practice Address - Zip Code:24244-5116
Practice Address - Country:US
Practice Address - Phone:276-431-2841
Practice Address - Fax:276-431-2345
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VANH2664314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4951344Medicaid
VA4960386Medicaid
VA4951344Medicaid