Provider Demographics
NPI:1093100919
Name:STAY AT HOME PERSONAL CARE LLC
Entity Type:Organization
Organization Name:STAY AT HOME PERSONAL CARE LLC
Other - Org Name:STAY AT HOME PERSONAL CARE GLOUCESTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:BRANDI
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:434-963-4949
Mailing Address - Street 1:PO BOX 2064
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22902-2064
Mailing Address - Country:US
Mailing Address - Phone:434-963-4949
Mailing Address - Fax:434-963-4940
Practice Address - Street 1:7657 MEREDITH DR
Practice Address - Street 2:
Practice Address - City:GLOUCESTER
Practice Address - State:VA
Practice Address - Zip Code:23061-4151
Practice Address - Country:US
Practice Address - Phone:804-767-3707
Practice Address - Fax:844-870-4780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-30
Last Update Date:2015-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAHCO-15848253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA01-60938236Medicaid
VA01-60938400Medicaid