Provider Demographics
NPI:1952126518
Name:KEYSTONE RESIDENTIAL LIVING LLC
Entity type:Organization
Organization Name:KEYSTONE RESIDENTIAL LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:COLEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:571-243-8164
Mailing Address - Street 1:4528 FORESTBURG LN
Mailing Address - Street 2:
Mailing Address - City:TRIANGLE
Mailing Address - State:VA
Mailing Address - Zip Code:22172-1705
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4528 FORESTBURG LN
Practice Address - Street 2:
Practice Address - City:TRIANGLE
Practice Address - State:VA
Practice Address - Zip Code:22172-1705
Practice Address - Country:US
Practice Address - Phone:571-243-8164
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-19
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness