Provider Demographics
NPI:1710234240
Name:NEW LIFE, LLC
Entity Type:Organization
Organization Name:NEW LIFE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CAO
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:E
Authorized Official - Last Name:ROMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-595-3890
Mailing Address - Street 1:11030 WARWICK BLVD BLDG B
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-3250
Mailing Address - Country:US
Mailing Address - Phone:757-595-3890
Mailing Address - Fax:757-595-3891
Practice Address - Street 1:11030 WARWICK BLVD BLDG B
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23601-3250
Practice Address - Country:US
Practice Address - Phone:757-595-3890
Practice Address - Fax:757-595-3891
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-15
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1729251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health