Provider Demographics
NPI:1932213956
Name:SUSAN CORNELIA RICE FAISON
Entity Type:Organization
Organization Name:SUSAN CORNELIA RICE FAISON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:CORNELIA RICE
Authorized Official - Last Name:FAISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-577-2780
Mailing Address - Street 1:PO BOX 60
Mailing Address - Street 2:
Mailing Address - City:VALENTINES
Mailing Address - State:VA
Mailing Address - Zip Code:23887-0060
Mailing Address - Country:US
Mailing Address - Phone:434-577-2780
Mailing Address - Fax:434-577-3023
Practice Address - Street 1:724 PARADISE DR
Practice Address - Street 2:
Practice Address - City:VALENTINES
Practice Address - State:VA
Practice Address - Zip Code:23887
Practice Address - Country:US
Practice Address - Phone:434-577-2780
Practice Address - Fax:434-577-3023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2008-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NONE332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7703383Medicaid
VA9120955Medicaid
NC7703383Medicaid