Provider Demographics
NPI:1871099721
Name:IMAGINATION LLC
Entity type:Organization
Organization Name:IMAGINATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF ADMINISTRATIVE OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-402-1356
Mailing Address - Street 1:PO BOX 28586
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23228-8586
Mailing Address - Country:US
Mailing Address - Phone:804-716-0593
Mailing Address - Fax:804-330-6698
Practice Address - Street 1:318 N WILKINSON RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23227-1631
Practice Address - Country:US
Practice Address - Phone:804-716-0593
Practice Address - Fax:804-330-6698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-31
Last Update Date:2018-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA3189-14-008322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children