Provider Demographics
NPI:1013407659
Name:FULL FOCUS TRAINING CENTER LLC
Entity Type:Organization
Organization Name:FULL FOCUS TRAINING CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LESLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:804-895-2106
Mailing Address - Street 1:P.O. BOX 213
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:VA
Mailing Address - Zip Code:23890-0213
Mailing Address - Country:US
Mailing Address - Phone:804-834-1100
Mailing Address - Fax:804-834-2200
Practice Address - Street 1:744 WEST MAIN STREET
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:VA
Practice Address - Zip Code:23890-0213
Practice Address - Country:US
Practice Address - Phone:804-834-1100
Practice Address - Fax:804-834-2200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-17
Last Update Date:2019-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA251S00000X, 261QM0850X, 261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No251S00000XAgenciesCommunity/Behavioral Health
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2960Medicaid
VA2960-02-011Medicaid