Provider Demographics
NPI:1558458893
Name:THE LAURELS OF UNIVERSITY PARK, LLC
Entity Type:Organization
Organization Name:THE LAURELS OF UNIVERSITY PARK, LLC
Other - Org Name:THE LAURELS OF UNIVERSITY PARK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:PATTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-794-8800
Mailing Address - Street 1:2420 PEMBERTON RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23233-2006
Mailing Address - Country:US
Mailing Address - Phone:804-747-9200
Mailing Address - Fax:
Practice Address - Street 1:2420 PEMBERTON RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23233-2006
Practice Address - Country:US
Practice Address - Phone:804-747-9200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VANH2705332BP3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4951093Medicaid
VANH2705OtherNH LICENSE #
VA221246OtherANTHEM BC/BS