Provider Demographics
NPI:1689243537
Name:LUCY CORR FOUNDATION, INC.
Entity Type:Organization
Organization Name:LUCY CORR FOUNDATION, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:HOLBERT
Authorized Official - Last Name:SHACKELFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-467-2255
Mailing Address - Street 1:6800 LUCY CORR BLVD.
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23832-6657
Mailing Address - Country:US
Mailing Address - Phone:804-467-2255
Mailing Address - Fax:
Practice Address - Street 1:6800 LUCY CORR BLVD.
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23832-6657
Practice Address - Country:US
Practice Address - Phone:804-467-2255
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-23
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0001XDental ProvidersDentistDental Public HealthGroup - Single Specialty