Provider Demographics
NPI:1194225037
Name:NIRVANA RESIDENTIAL SERVICES LLC
Entity Type:Organization
Organization Name:NIRVANA RESIDENTIAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-237-7717
Mailing Address - Street 1:1325 SMARTVIEW LN
Mailing Address - Street 2:
Mailing Address - City:FOREST
Mailing Address - State:VA
Mailing Address - Zip Code:24551-1099
Mailing Address - Country:US
Mailing Address - Phone:434-237-7717
Mailing Address - Fax:434-237-5668
Practice Address - Street 1:1325 SMARTVIEW LN
Practice Address - Street 2:
Practice Address - City:FOREST
Practice Address - State:VA
Practice Address - Zip Code:24551-1099
Practice Address - Country:US
Practice Address - Phone:434-237-7717
Practice Address - Fax:434-237-5668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-16
Last Update Date:2018-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities