Provider Demographics
NPI: | 1740412071 |
---|---|
Name: | ROANENTEPRISES, LLC |
Entity Type: | Organization |
Organization Name: | ROANENTEPRISES, LLC |
Other - Org Name: | 180 BOYS ADOLESCENT GROUP HOME |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | PRESIDENT/CEO |
Authorized Official - Prefix: | MR |
Authorized Official - First Name: | MARVIN |
Authorized Official - Middle Name: | VAN |
Authorized Official - Last Name: | ROANE |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 804-349-6382 |
Mailing Address - Street 1: | PO BOX 322 |
Mailing Address - Street 2: | |
Mailing Address - City: | RICHMOND |
Mailing Address - State: | VA |
Mailing Address - Zip Code: | 23218-0322 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 804-213-0540 |
Mailing Address - Fax: | 804-213-0542 |
Practice Address - Street 1: | 3122 W CLAY ST |
Practice Address - Street 2: | |
Practice Address - City: | RICHMOND |
Practice Address - State: | VA |
Practice Address - Zip Code: | 23230-4728 |
Practice Address - Country: | US |
Practice Address - Phone: | 804-213-0540 |
Practice Address - Fax: | 804-213-0542 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2009-08-20 |
Last Update Date: | 2009-08-20 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 103TP2701X | Behavioral Health & Social Service Providers | Psychologist | Group Psychotherapy | Group - Single Specialty |