Healthcare Provider Details

I. General information

NPI: 1104063254
Provider Name (Legal Business Name): MPOWERING KIDS MENTORING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2009
Last Update Date: 06/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 E MAIN ST
MARTINSVILLE VA
24112-2720
US

IV. Provider business mailing address

PO BOX 3229 34 E. MAIN STREET
MARTINSVILLE VA
24115-3229
US

V. Phone/Fax

Practice location:
  • Phone: 276-618-0759
  • Fax: 276-638-2680
Mailing address:
  • Phone: 276-634-0060
  • Fax: 276-632-2280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: VICKIE ADAMS
Title or Position: CEO
Credential:
Phone: 276-618-0759