Provider Demographics
NPI:1801180443
Name:PROFESSIONAL PARENT CARE LLC
Entity type:Organization
Organization Name:PROFESSIONAL PARENT CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:MR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:RYDELL
Authorized Official - Last Name:OWENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-778-5787
Mailing Address - Street 1:317 N ROSEMONT RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-3449
Mailing Address - Country:US
Mailing Address - Phone:757-323-2865
Mailing Address - Fax:757-962-4855
Practice Address - Street 1:317 N ROSEMONT RD
Practice Address - Street 2:SUITE 103
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-3449
Practice Address - Country:US
Practice Address - Phone:757-323-2865
Practice Address - Fax:757-962-4855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-31
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAS352074-1302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization