Provider Demographics
NPI:1053748954
Name:LOTTIE-ESTELLE GROUP HOME, INC
Entity type:Organization
Organization Name:LOTTIE-ESTELLE GROUP HOME, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:QMRP
Authorized Official - Prefix:MRS
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:TILLERSON
Authorized Official - Last Name:TERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-372-0407
Mailing Address - Street 1:4883 HWY 47
Mailing Address - Street 2:
Mailing Address - City:CHASE CITY
Mailing Address - State:VA
Mailing Address - Zip Code:23924-3606
Mailing Address - Country:US
Mailing Address - Phone:434-372-0407
Mailing Address - Fax:434-372-0394
Practice Address - Street 1:4897 HWY 47
Practice Address - Street 2:
Practice Address - City:CHASE CITY
Practice Address - State:VA
Practice Address - Zip Code:23924-3606
Practice Address - Country:US
Practice Address - Phone:434-372-0407
Practice Address - Fax:434-372-0394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-09
Last Update Date:2013-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA808315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities