Provider Demographics
NPI:1356825301
Name:COMMONWEALTH RESIDENTIAL LIVING LLC
Entity Type:Organization
Organization Name:COMMONWEALTH RESIDENTIAL LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-253-5529
Mailing Address - Street 1:232 TARABY DR
Mailing Address - Street 2:
Mailing Address - City:SANDSTON
Mailing Address - State:VA
Mailing Address - Zip Code:23150-2148
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:232 TARABY DR
Practice Address - Street 2:
Practice Address - City:SANDSTON
Practice Address - State:VA
Practice Address - Zip Code:23150-2148
Practice Address - Country:US
Practice Address - Phone:804-921-4237
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-16
Last Update Date:2018-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities