Provider Demographics
NPI:1952601866
Name:WCCB
Entity Type:Organization
Organization Name:WCCB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPTA
Authorized Official - Prefix:MRS
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:M
Authorized Official - Last Name:LARIOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-842-2437
Mailing Address - Street 1:1421 BRADEN CRES
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-2108
Mailing Address - Country:US
Mailing Address - Phone:757-842-2437
Mailing Address - Fax:
Practice Address - Street 1:3100 SHORE DRIVE
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23451-9864
Practice Address - Country:US
Practice Address - Phone:757-842-2437
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:000000000000000000
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-10-26
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306602413310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility