Provider Demographics
NPI:1891863973
Name:THERESA'-VENIA, LLC
Entity Type:Organization
Organization Name:THERESA'-VENIA, LLC
Other - Org Name:CORINE'S PLACE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LEOLIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-513-2074
Mailing Address - Street 1:4107 PORTSMOUTH BLVD
Mailing Address - Street 2:101-35
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23321-2140
Mailing Address - Country:US
Mailing Address - Phone:757-513-2074
Mailing Address - Fax:
Practice Address - Street 1:1536 CENTRE AVE
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23704-6802
Practice Address - Country:US
Practice Address - Phone:757-967-9545
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered310500000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Mental Illness
Not Answered315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0000005002OtherTRACKING NO