Provider Demographics
NPI:1750456646
Name:OLD DOMINION ADULT DAY CARE
Entity Type:Organization
Organization Name:OLD DOMINION ADULT DAY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ISABELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:HILLIARD
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:804-733-9093
Mailing Address - Street 1:2787 S CRATER RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23805-2471
Mailing Address - Country:US
Mailing Address - Phone:804-733-9037
Mailing Address - Fax:807-733-1169
Practice Address - Street 1:2787 S CRATER RD
Practice Address - Street 2:SUITE D
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23805-2471
Practice Address - Country:US
Practice Address - Phone:804-733-9037
Practice Address - Fax:807-733-1169
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health