1669574042 NPI number — COMMONWEALTH OF VIRGINIA CENTRAL STATE HOSPITAL

Table of content: (NPI 1669574042)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669574042 NPI number — COMMONWEALTH OF VIRGINIA CENTRAL STATE HOSPITAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMMONWEALTH OF VIRGINIA CENTRAL STATE HOSPITAL
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CENTRAL STATE HOPSITAL
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1669574042
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/01/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4030
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PETERSBURG
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23803-0030
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
26317 W WASHINGTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PETERSBURG
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23803
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-524-7000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DAVIS
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
Authorized Official Title or Position:
FACILITY DIRECTOR
Authorized Official Telephone Number:
804-524-7000

Provider Taxonomy Codes

  • Taxonomy code: 283Q00000X , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 49410701 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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