Provider Demographics
NPI:1225075294
Name:MARY IMMACULATE NURSING CENTER LLC
Entity Type:Organization
Organization Name:MARY IMMACULATE NURSING CENTER LLC
Other - Org Name:SAINT FRANCIS NURSING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SYSTEM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:RALSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-996-5119
Mailing Address - Street 1:8580 MAGELLAN PKWY
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23227-1149
Mailing Address - Country:US
Mailing Address - Phone:804-627-5573
Mailing Address - Fax:866-449-0896
Practice Address - Street 1:4 RIDGEWOOD PKWY
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23602-4415
Practice Address - Country:US
Practice Address - Phone:757-886-6500
Practice Address - Fax:757-886-6539
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-31
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VANH2695314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4952049Medicaid
VA227691OtherANTHEM PROVIDER NUMBER
VA004952049Medicaid
VA4952049Medicaid