1700894466 NPI number — VIRGINIA SOUTH PSYCHIATRIC & FAMILY SERVICES

Table of content: (NPI 1700894466)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700894466 NPI number — VIRGINIA SOUTH PSYCHIATRIC & FAMILY SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VIRGINIA SOUTH PSYCHIATRIC & FAMILY SERVICES
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:
Provider Other Organization Name Type Code:
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:
1700894466
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/12/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
269 MEDICAL PARK BLVD
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:
23805
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804-518-6504
Provider Business Mailing Address Fax Number:
804-863-4626

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
269 MEDICAL PARK BLVD
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:
23805
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-861-0700
Provider Business Practice Location Address Fax Number:
804-863-4626
Provider Enumeration Date:
08/04/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
VADELLA
Authorized Official First Name:
ANTHONY
Authorized Official Middle Name:
JOSEPH
Authorized Official Title or Position:
PRACTICE ADMINISTRATOR
Authorized Official Telephone Number:
804-518-6504

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 010325994 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".