Provider Demographics
NPI:1962280727
Name:SUPPORTIVE RESIDENTIAL LLC
Entity type:Organization
Organization Name:SUPPORTIVE RESIDENTIAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-305-4790
Mailing Address - Street 1:8005 REEDY BRANCH RD
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23838-5710
Mailing Address - Country:US
Mailing Address - Phone:804-305-4790
Mailing Address - Fax:
Practice Address - Street 1:934 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23223-6190
Practice Address - Country:US
Practice Address - Phone:804-305-4790
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-21
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation SpecialistGroup - Single Specialty