Healthcare Provider Details

I. General information

NPI: 1972940880
Provider Name (Legal Business Name): MBHS OF KENBRIDGE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2013
Last Update Date: 06/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

231 HICKORY RD
KENBRIDGE VA
23944-3503
US

IV. Provider business mailing address

231 HICKORY RD
KENBRIDGE VA
23944-3503
US

V. Phone/Fax

Practice location:
  • Phone: 454-676-1378
  • Fax:
Mailing address:
  • Phone: 454-676-1378
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number2139
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number2136-14-001
License Number StateVA

VIII. Authorized Official

Name: PATRICIA HAMILTON
Title or Position: CHIEF ADMINISTRATIVE OFFICER
Credential:
Phone: 454-676-1378