Provider Demographics
NPI:1427588227
Name:MENTAL WELLNESS RESIDENTIAL
Entity Type:Organization
Organization Name:MENTAL WELLNESS RESIDENTIAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:VALERIE
Authorized Official - Middle Name:B
Authorized Official - Last Name:UDOFIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-697-7991
Mailing Address - Street 1:PO BOX 3628
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24115-3628
Mailing Address - Country:US
Mailing Address - Phone:919-697-7991
Mailing Address - Fax:
Practice Address - Street 1:1420 SPRUCE STREET EXTRENSION
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24412
Practice Address - Country:US
Practice Address - Phone:276-790-3473
Practice Address - Fax:276-632-2010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-14
Last Update Date:2017-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness