Provider Demographics
NPI:1912341926
Name:PERSON CENTERED PLACE, LLC
Entity Type:Organization
Organization Name:PERSON CENTERED PLACE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF SERVICE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JUANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:ANTRUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-227-6081
Mailing Address - Street 1:4667 HAYGOOD RD
Mailing Address - Street 2:# 506
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-5444
Mailing Address - Country:US
Mailing Address - Phone:757-227-6081
Mailing Address - Fax:757-227-6082
Practice Address - Street 1:4667 HAYGOOD RD
Practice Address - Street 2:# 506
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23455-5444
Practice Address - Country:US
Practice Address - Phone:757-227-6081
Practice Address - Fax:757-227-6082
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-20
Last Update Date:2013-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1823-02-006251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health