=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003259771
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VIRGINIA BEHAVIORAL MEDICINE PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/12/2013
-----------------------------------------------------
Last Update Date | 07/18/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1301 FIRST COLONIAL RD STE 200
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23454-2263
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-222-1230
-----------------------------------------------------
Fax | 757-222-1887
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1301 FIRST COLONIAL RD STE 200
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23454-2263
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-222-1230
-----------------------------------------------------
Fax | 757-222-1887
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JOHN F RIEDLER
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 757-373-0380
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 323P00000X
-----------------------------------------------------
Taxonomy Name | Psychiatric Residential Treatment Facility
-----------------------------------------------------
License Number | 0101054894
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------