Provider Demographics
NPI:1649386244
Name:BON SECOURS PRIVATE CARE
Entity Type:Organization
Organization Name:BON SECOURS PRIVATE CARE
Other - Org Name:PROFESSIONAL HEALTH CARE
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:G
Authorized Official - Last Name:BALLARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-213-7907
Mailing Address - Street 1:3636 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23707-3236
Mailing Address - Country:US
Mailing Address - Phone:757-889-4662
Mailing Address - Fax:757-213-7945
Practice Address - Street 1:861 GLENROCK RD STE 155
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-3718
Practice Address - Country:US
Practice Address - Phone:757-889-4662
Practice Address - Fax:757-213-7945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2008-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA010075661251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA008770531Medicaid
VA008701652Medicaid