Provider Demographics
NPI:1902255235
Name:PARKERLANE ASSISTANT LIVING FACILITY
Entity Type:Organization
Organization Name:PARKERLANE ASSISTANT LIVING FACILITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MISS
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:YVETTE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-748-2670
Mailing Address - Street 1:12706 PARKER LN
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23831-5130
Mailing Address - Country:US
Mailing Address - Phone:804-748-2670
Mailing Address - Fax:180-058-3495
Practice Address - Street 1:12706 PARKER LN
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:VA
Practice Address - Zip Code:23831-5130
Practice Address - Country:US
Practice Address - Phone:804-748-2670
Practice Address - Fax:180-058-3495
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-07
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0167642211Medicaid