Provider Demographics
NPI:1659764629
Name:V&V ADULT GROUP HOME, LLC
Entity Type:Organization
Organization Name:V&V ADULT GROUP HOME, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:VERNON
Authorized Official - Middle Name:TYRONE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-439-0853
Mailing Address - Street 1:1037 SEAN DR
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23323-2727
Mailing Address - Country:US
Mailing Address - Phone:757-439-0853
Mailing Address - Fax:757-673-4877
Practice Address - Street 1:1037 SEAN DR
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23323-2727
Practice Address - Country:US
Practice Address - Phone:757-439-0853
Practice Address - Fax:757-673-4877
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-13
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA142101001320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0162498072Medicaid