Provider Demographics
NPI:1619561792
Name:FINE FRUIT RESIDENTIAL LLC
Entity Type:Organization
Organization Name:FINE FRUIT RESIDENTIAL LLC
Other - Org Name:FINE FRUIT RESIDENTIAL LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:BUIE-FLYTHE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-528-1449
Mailing Address - Street 1:3807 AUGUSTINE CIR
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23703-2502
Mailing Address - Country:US
Mailing Address - Phone:757-528-1449
Mailing Address - Fax:
Practice Address - Street 1:3711 PALM CT
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23703-2625
Practice Address - Country:US
Practice Address - Phone:757-528-1449
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-01
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services