Provider Demographics
NPI:1083498380
Name:COX, RENARD LAVELL
Entity Type:Individual
Prefix:
First Name:RENARD
Middle Name:LAVELL
Last Name:COX
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4313 TOSH LN
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23831-6855
Mailing Address - Country:US
Mailing Address - Phone:804-475-4907
Mailing Address - Fax:
Practice Address - Street 1:3143 ZION ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23234-1640
Practice Address - Country:US
Practice Address - Phone:804-617-0969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-21
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA443501001320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities