Provider Demographics
NPI:1255143681
Name:WOODRUFF RESIDENTIAL LLC
Entity type:Organization
Organization Name:WOODRUFF RESIDENTIAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SHAVONNE
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:804-402-1894
Mailing Address - Street 1:1924 WHITE MOUNTAIN DR
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23836-3008
Mailing Address - Country:US
Mailing Address - Phone:804-402-1894
Mailing Address - Fax:
Practice Address - Street 1:1924 WHITE MOUNTAIN DR
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:VA
Practice Address - Zip Code:23836-3008
Practice Address - Country:US
Practice Address - Phone:804-402-1894
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-22
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services