Healthcare Provider Details

I. General information

NPI: 1003362484
Provider Name (Legal Business Name): BHG XLII, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2016
Last Update Date: 12/18/2024
Certification Date: 12/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5715 PRINCESS ANNE RD
VIRGINIA BEACH VA
23462-3222
US

IV. Provider business mailing address

5001 SPRING VALLEY RD SUITE 600 EAST
DALLAS TX
75244-3946
US

V. Phone/Fax

Practice location:
  • Phone: 757-962-0748
  • Fax:
Mailing address:
  • Phone: 214-365-6100
  • Fax: 214-365-6150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number2967
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number2967
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number2967
License Number StateVA

VIII. Authorized Official

Name: JAY HIGHAM
Title or Position: CEO
Credential:
Phone: 214-365-6112