Healthcare Provider Details

I. General information

NPI: 1346423225
Provider Name (Legal Business Name): CAROLINE OUTPATIENT PROGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2007
Last Update Date: 12/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7120 CONWAY PLACE
RUTHER GLEN VA
22546
US

IV. Provider business mailing address

PO BOX 615
LADYSMITH VA
22501-0615
US

V. Phone/Fax

Practice location:
  • Phone: 804-305-5954
  • Fax:
Mailing address:
  • Phone: 804-305-5954
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. SHERONDA W. WINGO
Title or Position: CEO/DIRECTOR
Credential:
Phone: 804-589-0022