Provider Demographics
NPI:1346423894
Name:FOURTH BAY VENTURES, LLC
Entity Type:Organization
Organization Name:FOURTH BAY VENTURES, LLC
Other - Org Name:OWENS GROUP HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE-PRESIDENT/TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:OWENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-539-2245
Mailing Address - Street 1:106 NEWTOWN CT
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-9299
Mailing Address - Country:US
Mailing Address - Phone:757-539-2245
Mailing Address - Fax:
Practice Address - Street 1:166 S SARATOGA ST
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-5357
Practice Address - Country:US
Practice Address - Phone:757-923-0480
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-06
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness