Provider Demographics
NPI:1811755630
Name:SOPHISTICARE
Entity type:Organization
Organization Name:SOPHISTICARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PHILICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CAILLOT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-905-0428
Mailing Address - Street 1:1403 LINDSAY AVE
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23704-6917
Mailing Address - Country:US
Mailing Address - Phone:617-905-0428
Mailing Address - Fax:
Practice Address - Street 1:1403 LINDSAY AVE
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23704-6917
Practice Address - Country:US
Practice Address - Phone:617-905-0428
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-07
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities