Provider Demographics
NPI:1225178312
Name:WEST LAKE RESIDENTIAL FACILITY
Entity Type:Organization
Organization Name:WEST LAKE RESIDENTIAL FACILITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JIMMIE
Authorized Official - Middle Name:JUNIOR
Authorized Official - Last Name:PRATT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-560-9774
Mailing Address - Street 1:PO BOX 4506
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112
Mailing Address - Country:US
Mailing Address - Phone:804-560-9774
Mailing Address - Fax:804-560-9776
Practice Address - Street 1:6946 FOREST HILL AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23225-1606
Practice Address - Country:US
Practice Address - Phone:804-560-9774
Practice Address - Fax:804-560-9776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0459320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities