Provider Demographics
NPI:1003697392
Name:REVAMP SUPPORT RESIDENTIAL SERVICES LLP
Entity Type:Organization
Organization Name:REVAMP SUPPORT RESIDENTIAL SERVICES LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:STRAFFORD
Authorized Official - Middle Name:ACHANYI
Authorized Official - Last Name:NGOSONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-820-6698
Mailing Address - Street 1:2851 HEADWAY DR
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-6042
Mailing Address - Country:US
Mailing Address - Phone:202-820-6698
Mailing Address - Fax:
Practice Address - Street 1:2851 HEADWAY DR
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-6042
Practice Address - Country:US
Practice Address - Phone:202-820-6698
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-11
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services