Provider Demographics
NPI:1144699034
Name:GROUP RESIDENTIAL AND CARE ESTABLISHMENT
Entity type:Organization
Organization Name:GROUP RESIDENTIAL AND CARE ESTABLISHMENT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RODNEY
Authorized Official - Middle Name:JEROME
Authorized Official - Last Name:HAWKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-325-8399
Mailing Address - Street 1:PO BOX 8227
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-0280
Mailing Address - Country:US
Mailing Address - Phone:757-325-8399
Mailing Address - Fax:757-325-8321
Practice Address - Street 1:2021B CUNNINGHAM DR
Practice Address - Street 2:SUITE 3
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-3326
Practice Address - Country:US
Practice Address - Phone:757-325-8399
Practice Address - Fax:757-325-8321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-21
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA71303011253Z00000X
VA71301001320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0101420900Medicaid