Provider Demographics
NPI:1487963823
Name:BETH SHOLOM HOME OF EASTERN VIRGINIA
Entity type:Organization
Organization Name:BETH SHOLOM HOME OF EASTERN VIRGINIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF THERAPY SERVICES
Authorized Official - Prefix:MRS
Authorized Official - First Name:NINA
Authorized Official - Middle Name:
Authorized Official - Last Name:MUNGO
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:757-420-1485
Mailing Address - Street 1:6401 AUBURN DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-3601
Mailing Address - Country:US
Mailing Address - Phone:757-420-1485
Mailing Address - Fax:
Practice Address - Street 1:6401 AUBURN DR
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-3601
Practice Address - Country:US
Practice Address - Phone:757-420-1485
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-04
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306602919314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility