Provider Demographics
NPI:1447481437
Name:MILESTONE HOUSE, LLC
Entity type:Organization
Organization Name:MILESTONE HOUSE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LOVONNE
Authorized Official - Middle Name:RAYNE
Authorized Official - Last Name:VANCE
Authorized Official - Suffix:
Authorized Official - Credentials:MS, NCC
Authorized Official - Phone:276-988-0872
Mailing Address - Street 1:30552 GOVERNOR G C PEERY HWY
Mailing Address - Street 2:
Mailing Address - City:N TAZEWELL
Mailing Address - State:VA
Mailing Address - Zip Code:24630-8339
Mailing Address - Country:US
Mailing Address - Phone:276-988-0872
Mailing Address - Fax:276-988-0876
Practice Address - Street 1:30552 GOVERNOR G C PEERY HWY
Practice Address - Street 2:
Practice Address - City:N TAZEWELL
Practice Address - State:VA
Practice Address - Zip Code:24630-8339
Practice Address - Country:US
Practice Address - Phone:276-988-0872
Practice Address - Fax:276-988-0876
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-07
Last Update Date:2009-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VACO-434-09322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children