Healthcare Provider Details

I. General information

NPI: 1467448571
Provider Name (Legal Business Name): GOOCHLAND POWHATAN COMMUNITY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2005
Last Update Date: 02/09/2022
Certification Date: 02/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3058 RIVER RD W
GOOCHLAND VA
23063-3202
US

IV. Provider business mailing address

PO BOX 189
GOOCHLAND VA
23063-0189
US

V. Phone/Fax

Practice location:
  • Phone: 804-556-5400
  • Fax: 804-556-5403
Mailing address:
  • Phone: 804-556-5400
  • Fax: 804-556-5403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number207
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name: LESTER SALTZBERG
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 804-556-5400