Provider Demographics
NPI:1376202051
Name:1ST PROMISE RESIDENTIAL SERVICES, LLC
Entity Type:Organization
Organization Name:1ST PROMISE RESIDENTIAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FERDINAND
Authorized Official - Middle Name:
Authorized Official - Last Name:ATABONGAWUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:571-278-1273
Mailing Address - Street 1:10127 WOODBURY DR APT 512
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20109-3781
Mailing Address - Country:US
Mailing Address - Phone:571-278-1273
Mailing Address - Fax:
Practice Address - Street 1:10127 WOODBURY DR APT 512
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20109-3781
Practice Address - Country:US
Practice Address - Phone:571-278-1273
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-10
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA3979Medicaid