Provider Demographics
NPI:1497070296
Name:INFINITE POTENTIAL SUPPORTIVE SERVICES, LLC
Entity Type:Organization
Organization Name:INFINITE POTENTIAL SUPPORTIVE SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTER/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:L
Authorized Official - Last Name:MURPHY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:276-523-2797
Mailing Address - Street 1:PO BOX 390
Mailing Address - Street 2:2114 AVON STREET
Mailing Address - City:EAST STONE GAP
Mailing Address - State:VA
Mailing Address - Zip Code:24246-0390
Mailing Address - Country:US
Mailing Address - Phone:276-523-2797
Mailing Address - Fax:276-523-2797
Practice Address - Street 1:2114 AVON STREET
Practice Address - Street 2:
Practice Address - City:EAST STONE GAP
Practice Address - State:VA
Practice Address - Zip Code:24246
Practice Address - Country:US
Practice Address - Phone:276-523-2797
Practice Address - Fax:276-523-2797
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-05
Last Update Date:2010-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1213320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities