Provider Demographics
NPI:1013761725
Name:BANNER OF SUPPORT LLC
Entity Type:Organization
Organization Name:BANNER OF SUPPORT LLC
Other - Org Name:BANNER OF SUPPORT
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GAIL
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:JEFFREY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-251-0655
Mailing Address - Street 1:PO BOX 5435
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23605-0435
Mailing Address - Country:US
Mailing Address - Phone:757-251-0655
Mailing Address - Fax:757-325-6685
Practice Address - Street 1:3411 SUNNYSIDE DR
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-3706
Practice Address - Country:US
Practice Address - Phone:757-251-0655
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-17
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251B00000XAgenciesCase Management
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty