Provider Demographics
NPI:1558677658
Name:MASONIC HOME OF VIRGINIA
Entity Type:Organization
Organization Name:MASONIC HOME OF VIRGINIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:D
Authorized Official - Last Name:COLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-222-1694
Mailing Address - Street 1:4101 NINE MILE RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23223-4956
Mailing Address - Country:US
Mailing Address - Phone:804-222-1694
Mailing Address - Fax:804-226-4567
Practice Address - Street 1:4101 NINE MILE RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23223-4956
Practice Address - Country:US
Practice Address - Phone:804-222-1694
Practice Address - Fax:804-226-4567
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-26
Last Update Date:2010-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VANH2628313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility