Healthcare Provider Details

I. General information

NPI: 1790084804
Provider Name (Legal Business Name): THE INDEPENDENT CAPACITY SYSTEM, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2011
Last Update Date: 03/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16015 CONTINENTAL BLVD
COLONIAL HEIGHTS VA
23834-5900
US

IV. Provider business mailing address

PO BOX 3163
PETERSBURG VA
23805-3163
US

V. Phone/Fax

Practice location:
  • Phone: 804-721-1720
  • Fax: 804-214-2177
Mailing address:
  • Phone: 804-721-1720
  • Fax: 804-214-2177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number StateVA

VIII. Authorized Official

Name: MR. PASCAL THEBAUD
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 804-721-1720