MEDICARE: LIFE SUPPORT MH COMMUNITY SUPPORT SERVICES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency		VA

General Provider Information

NPI Number	:	1295010189
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFE SUPPORT MH COMMUNITY SUPPORT SERVICES

Provider Business Mailing Address
First Line	:	349 PINEY FOREST RD
Second Line	:	SUITE A
City	:	DANVILLE
State	:	VA
Zip	:	24540-4121
Country	:	US
Telephone Number	:	434-728-2641
Fax Number	:

Provider Business Practice Location Address
First Line	:	490 PINEY FOREST RD
Second Line	:
City	:	DANVILLE
State	:	VA
Zip	:	24540-4060
Country	:	US
Telephone Number	:	434-728-2641
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MS. KIMBERLY HARPER GIBSON
Credential	:	RN
Telephone Number	:	434-728-2641

Provider Enumeration Date	:	10/11/2011
Last Update Date	:	12/06/2024

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