Provider Demographics
NPI:1447352042
Name:RESIDENTIAL LIVING OPTIONS LLC
Entity type:Organization
Organization Name:RESIDENTIAL LIVING OPTIONS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:LYDELL
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:757-477-1221
Mailing Address - Street 1:1013 SAINT ANDREWS WAY APT C
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-8524
Mailing Address - Country:US
Mailing Address - Phone:757-410-0229
Mailing Address - Fax:
Practice Address - Street 1:3314 LENS AVE
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23509-2610
Practice Address - Country:US
Practice Address - Phone:757-855-3782
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-02
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA725-01-001320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010109566Medicaid