Provider Demographics
NPI:1518732965
Name:REFUEL LIFE TRAUMA CENTER, LLC
Entity Type:Organization
Organization Name:REFUEL LIFE TRAUMA CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PROFESSIONAL COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:PATRICE
Authorized Official - Middle Name:DANIELLE
Authorized Official - Last Name:MURPHY
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, NCC
Authorized Official - Phone:757-453-4110
Mailing Address - Street 1:100 SABAL PALM LN APT 303
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-1734
Mailing Address - Country:US
Mailing Address - Phone:757-288-8794
Mailing Address - Fax:
Practice Address - Street 1:100 SABAL PALM LN APT 303
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-1734
Practice Address - Country:US
Practice Address - Phone:757-288-8794
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-15
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1629719786OtherINDIVIDUAL NNPI TYPE 1