Provider Demographics
NPI:1447494042
Name:SEEDS OF CHANGE, LLC
Entity type:Organization
Organization Name:SEEDS OF CHANGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:AARON
Authorized Official - Middle Name:BERNARD
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:757-647-2407
Mailing Address - Street 1:2015 LIVERPOOL ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23704-3049
Mailing Address - Country:US
Mailing Address - Phone:757-606-3284
Mailing Address - Fax:757-606-3284
Practice Address - Street 1:2015 LIVERPOOL ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23704-3049
Practice Address - Country:US
Practice Address - Phone:757-606-3284
Practice Address - Fax:757-606-3284
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-27
Last Update Date:2009-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1078-014-001320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAKAR1112Medicaid