Healthcare Provider Details

I. General information

NPI: 1265677934
Provider Name (Legal Business Name): VIRGINIA HOME FOR BOYS AND GIRLS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2008
Last Update Date: 09/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2250 PUMP RD
RICHMOND VA
23233-3508
US

IV. Provider business mailing address

8716 W BROAD ST
RICHMOND VA
23294-6209
US

V. Phone/Fax

Practice location:
  • Phone: 804-447-3527
  • Fax: 804-447-3960
Mailing address:
  • Phone: 804-270-6566
  • Fax: 804-934-9013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License NumberSS-78-07
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number1438-14-001
License Number StateVA

VIII. Authorized Official

Name: MR. JOHN BURGETT DOUGHERTY
Title or Position: SVP/CHIEF ADMINISTRATIVE OFFICER
Credential: M.S.W.
Phone: 804-270-6566