Basic Information
| Provider Information | |||||||||
| NPI: | 1790836831 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FRONTIER HEALTH | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PARK PLACE RESIDENTIAL SERVICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9054 | ||||||||
| Address2: | |||||||||
| City: | GRAY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376159054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234673600 | ||||||||
| FaxNumber: | 4234673644 | ||||||||
| Practice Location | |||||||||
| Address1: | 103 FRALEY AVE | ||||||||
| Address2: | |||||||||
| City: | DUFFIELD | ||||||||
| State: | VA | ||||||||
| PostalCode: | 242449798 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2764431415 | ||||||||
| FaxNumber: | 2764312640 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | VARNEY | ||||||||
| AuthorizedOfficialFirstName: | E | ||||||||
| AuthorizedOfficialMiddleName: | DOUGLAS | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 4234673600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320900000X | 315-01-001 | VA | X | Residential Treatment Facilities | Community Based Residential Treatment, Mental Retardation and/or Developmental Disabilities | 385HR2060X | 315-01-001 | VA | X | Respite Care Facility | Respite Care | Respite Care, Mental Retardation and/or Developmental Disabilities, Child |
No ID Information.