Healthcare Provider Details

I. General information

NPI: 1134596224
Provider Name (Legal Business Name): PENINSULA AGENCY ON AGING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2015
Last Update Date: 08/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

739 THIMBLE SHOALS BLVD BUILDING 1000, STE 1006
NEWPORT NEWS VA
23606-3562
US

IV. Provider business mailing address

739 THIMBLE SHOALS BLVD BUILDING 1000, STE 1006
NEWPORT NEWS VA
23606-3562
US

V. Phone/Fax

Practice location:
  • Phone: 757-873-0541
  • Fax: 757-873-1437
Mailing address:
  • Phone: 757-873-0541
  • Fax: 757-873-1437

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. WILLIAM S MASSEY
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 757-873-0541