Provider Demographics
NPI:1568793669
Name:GREATER WILLIAMSBURG RESIDENTIAL FACILITY, LP.
Entity Type:Organization
Organization Name:GREATER WILLIAMSBURG RESIDENTIAL FACILITY, LP.
Other - Org Name:GREATER WILLIAMSBURG RESIDENTIAL FACILITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PATRICE
Authorized Official - Middle Name:
Authorized Official - Last Name:MUHAMMAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-903-4236
Mailing Address - Street 1:602 TAM O SHANTER BLVD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23185-5922
Mailing Address - Country:US
Mailing Address - Phone:757-903-4236
Mailing Address - Fax:
Practice Address - Street 1:602 TAM O SHANTER BLVD
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23185-5922
Practice Address - Country:US
Practice Address - Phone:757-903-4236
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DESTINYS HOUSE RESIDENTIAL SERVICES, LLC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-01-29
Last Update Date:2010-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA990320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities