Provider Demographics
NPI:1740217918
Name:ST MARYS HOME FOR DISABLED CHILDREN
Entity Type:Organization
Organization Name:ST MARYS HOME FOR DISABLED CHILDREN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:C
Authorized Official - Last Name:GIERMAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-622-2208
Mailing Address - Street 1:6171 KEMPSVILLE CIRCLE
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-3930
Mailing Address - Country:US
Mailing Address - Phone:757-622-2208
Mailing Address - Fax:757-640-0147
Practice Address - Street 1:6171 KEMPSVILLE CIRCLE
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-3930
Practice Address - Country:US
Practice Address - Phone:757-622-2208
Practice Address - Fax:757-640-0147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-26
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA30414001315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004966333Medicaid