Provider Demographics
NPI:1184180085
Name:HOTEP HOME
Entity Type:Organization
Organization Name:HOTEP HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DARIO
Authorized Official - Middle Name:L
Authorized Official - Last Name:WATERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-652-3058
Mailing Address - Street 1:5905 DUNKIRK ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23703-3129
Mailing Address - Country:US
Mailing Address - Phone:757-652-3058
Mailing Address - Fax:
Practice Address - Street 1:5905 DUNKIRK ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23703-3129
Practice Address - Country:US
Practice Address - Phone:757-652-3058
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-15
Last Update Date:2019-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services