Healthcare Provider Details

I. General information

NPI: 1114027521
Provider Name (Legal Business Name): COMMONWEALTH OF VIRGINIA DEPARTMENT OF BEHAVI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 06/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4601 IRONBOUND RD
WILLIAMSBURG VA
23188-2652
US

IV. Provider business mailing address

4601 IRONBOUND RD
WILLIAMSBURG VA
23188-2652
US

V. Phone/Fax

Practice location:
  • Phone: 757-253-5241
  • Fax: 757-253-5065
Mailing address:
  • Phone: 757-253-5241
  • Fax: 757-253-5065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310500000X
TaxonomyMental Illness Intermediate Care Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. JACK L.. WOOD
Title or Position: HOSPITAL DIRECTOR
Credential: NHA
Phone: 757-253-5241