Provider Demographics
NPI:1811584469
Name:GARRISONS SUPPORTIVE LIVING
Entity Type:Organization
Organization Name:GARRISONS SUPPORTIVE LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERKIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-779-4493
Mailing Address - Street 1:1253 W 27TH ST
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23508-2442
Mailing Address - Country:US
Mailing Address - Phone:757-779-4493
Mailing Address - Fax:
Practice Address - Street 1:1253 W 27TH ST
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23508-2442
Practice Address - Country:US
Practice Address - Phone:757-779-4493
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-30
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities