Provider Demographics
NPI:1437571536
Name:LIVE IMPACT DAY SUPPORT
Entity Type:Organization
Organization Name:LIVE IMPACT DAY SUPPORT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PROGRAM DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRIDGET
Authorized Official - Middle Name:
Authorized Official - Last Name:OLUGBEMI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-814-4845
Mailing Address - Street 1:PO BOX 4667
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-0011
Mailing Address - Country:US
Mailing Address - Phone:804-814-4845
Mailing Address - Fax:804-276-2536
Practice Address - Street 1:7200 BEACH RD
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23838-6505
Practice Address - Country:US
Practice Address - Phone:804-814-4845
Practice Address - Fax:804-276-2536
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMPASSIONATE HEARTS FAMILY SERVICES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-01-09
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1093-02-006251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services