Provider Demographics
NPI:1255684858
Name:JUSTIN'S BLACK TEA AND BREAD, A TEA ROOM LLC
Entity Type:Organization
Organization Name:JUSTIN'S BLACK TEA AND BREAD, A TEA ROOM LLC
Other - Org Name:PEOPLES HEALTHCARE FACILITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:PROCTOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-589-5432
Mailing Address - Street 1:1001 PROVIDENCE ST
Mailing Address - Street 2:STE 203
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22554-8300
Mailing Address - Country:US
Mailing Address - Phone:703-589-5432
Mailing Address - Fax:540-657-9732
Practice Address - Street 1:1001 PROVIDENCE ST
Practice Address - Street 2:STE 203
Practice Address - City:STAFFORD
Practice Address - State:VA
Practice Address - Zip Code:22554-8300
Practice Address - Country:US
Practice Address - Phone:703-589-5432
Practice Address - Fax:540-657-9732
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-19
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service