Provider Demographics
NPI:1932502127
Name:POTENTIALS IN LIFE LLC
Entity Type:Organization
Organization Name:POTENTIALS IN LIFE LLC
Other - Org Name:P.I.L.
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO/PROGRAM DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRELL
Authorized Official - Middle Name:
Authorized Official - Last Name:CUFFEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-735-0154
Mailing Address - Street 1:522 S INDEPENDENCE BLVD STE 102C
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-1149
Mailing Address - Country:US
Mailing Address - Phone:757-735-0153
Mailing Address - Fax:
Practice Address - Street 1:522 S INDEPENDENCE BLVD STE 102C
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-1149
Practice Address - Country:US
Practice Address - Phone:757-735-0153
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-01
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1681-03-001251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health