Provider Demographics
NPI:1972757995
Name:HOUSE OF REFUGE RESTORATION,LLC
Entity Type:Organization
Organization Name:HOUSE OF REFUGE RESTORATION,LLC
Other - Org Name:HOUSE OF REFUGE MINISTRIES, LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TEISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:ETHERIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:757-560-1944
Mailing Address - Street 1:805 SHADOWBERRY CREST
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-3544
Mailing Address - Country:US
Mailing Address - Phone:757-560-1944
Mailing Address - Fax:877-468-5361
Practice Address - Street 1:805 SHADOWBERRY CRST
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-3544
Practice Address - Country:US
Practice Address - Phone:757-436-2201
Practice Address - Fax:877-468-5361
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-05
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA320800000X, 320900000X, 322D00000X, 385HR2055X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1326230640Medicaid
VA117414794Medicaid