Healthcare Provider Details

I. General information

NPI: 1962988139
Provider Name (Legal Business Name): SOUND MIND ADC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2018
Last Update Date: 07/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4411 WISTAR RD
HENRICO VA
23228
US

IV. Provider business mailing address

4411 WISTAR RD
HENRICO VA
23228-2640
US

V. Phone/Fax

Practice location:
  • Phone: 804-922-7203
  • Fax:
Mailing address:
  • Phone: 804-922-7203
  • Fax: 804-262-1576

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. ELLIS HENDERSON
Title or Position: OWNER
Credential:
Phone: 804-852-7645