MEDICARE: HAMLET HOUSE YOUTH SERVICES, III LLC

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	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility	1347-14-001	VA
2	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility	1347-14-001	VA

General Provider Information

NPI Number	:	1366790107
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HAMLET HOUSE YOUTH SERVICES, III LLC

Provider Business Mailing Address
First Line	:	517 CLAUSON RD
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23227-1203
Country	:	US
Telephone Number	:	804-326-9046
Fax Number	:

Provider Business Practice Location Address
First Line	:	206 CARLSTONE DR
Second Line	:
City	:	HIGHLAND SPRINGS
State	:	VA
Zip	:	23075-2503
Country	:	US
Telephone Number	:	804-326-9046
Fax Number	:	804-326-9046

Authorized Official
Title or Position	:	CHIEF ADMINISTRATIVE OFFICE
Name	:	MRS. GWENDOLYN SCURLOCK INGRAM
Credential	:
Telephone Number	:	804-326-9046

Provider Enumeration Date	:	08/28/2012
Last Update Date	:	08/28/2012

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