Provider Demographics
NPI:1346684974
Name:INNOVAGE VIRGINIA PACE - ROANOKE VALLEY, LLC
Entity Type:Organization
Organization Name:INNOVAGE VIRGINIA PACE - ROANOKE VALLEY, LLC
Other - Org Name:INNOVAGE VIRGINIA PACE - ROANOKE VALLEY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGIONAL EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSH
Authorized Official - Middle Name:D
Authorized Official - Last Name:MCGILLIARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-595-6563
Mailing Address - Street 1:5251 CONCOURSE DR
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24019-3081
Mailing Address - Country:US
Mailing Address - Phone:540-904-2817
Mailing Address - Fax:540-682-5946
Practice Address - Street 1:5251 CONCOURSE DR
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24019-3081
Practice Address - Country:US
Practice Address - Phone:540-904-2817
Practice Address - Fax:540-682-5946
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TOTAL COMMUNITY OPTIONS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-04-25
Last Update Date:2018-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA251T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251T00000XAgenciesProgram of All-Inclusive Care for the Elderly (PACE) Provider Organization