Provider Demographics
NPI:1013215409
Name:NOBLE CARELLC
Entity Type:Organization
Organization Name:NOBLE CARELLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:A
Authorized Official - Last Name:MYRICK
Authorized Official - Suffix:
Authorized Official - Credentials:BACHELORS DEGREE I
Authorized Official - Phone:757-303-5846
Mailing Address - Street 1:225 HOLBROOK ARCH
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-2157
Mailing Address - Country:US
Mailing Address - Phone:757-303-5846
Mailing Address - Fax:757-538-0064
Practice Address - Street 1:507 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:VA
Practice Address - Zip Code:23851-1556
Practice Address - Country:US
Practice Address - Phone:757-303-5846
Practice Address - Fax:757-538-0064
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-09
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1602-01-001320600000X, 320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0163118638Medicaid