Provider Demographics
NPI:1528712387
Name:301 VILLAGE HOLDINGS LLC
Entity type:Organization
Organization Name:301 VILLAGE HOLDINGS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:BARUCH
Authorized Official - Middle Name:
Authorized Official - Last Name:GIBERSTIEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-415-8090
Mailing Address - Street 1:301 VILLAGE CIR
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:VA
Mailing Address - Zip Code:24201-8302
Mailing Address - Country:US
Mailing Address - Phone:276-477-5334
Mailing Address - Fax:
Practice Address - Street 1:301 VILLAGE CIR
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:VA
Practice Address - Zip Code:24201-8302
Practice Address - Country:US
Practice Address - Phone:276-477-5334
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-09
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
VANH2783Medicaid
VA1528712387OtherANTHEM HEALTH KEEPERS PLUS