1497717615 NPI number — MIDDLE PENINSULA NORTHERN NECK MENTAL HEALTH & RETARDATION

Table of content: (NPI 1497717615)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497717615 NPI number — MIDDLE PENINSULA NORTHERN NECK MENTAL HEALTH & RETARDATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIDDLE PENINSULA NORTHERN NECK MENTAL HEALTH & RETARDATION
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:
MIDDLE PENINSULA NORTHERN NECK COUNSELING CENTER
Provider Other Organization Name Type Code:
5
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:
1497717615
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/21/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 269
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ARK
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23003-0269
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804-693-5640
Provider Business Mailing Address Fax Number:
804-693-4822

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9228 GEORGE WASHINGTON MEMORIAL HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLOUCESTER
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23061-4162
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-693-5068
Provider Business Practice Location Address Fax Number:
804-693-7407
Provider Enumeration Date:
04/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WINGROVE
Authorized Official First Name:
YVONNE
Authorized Official Middle Name:
M
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
804-693-5640

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1497717615 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 294721 . This is a "VALUE OPTIONS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 250204 . This is a "ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 250208 . This is a "ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 004945115 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 250202 . This is a "ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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