=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043653645
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OUTREACH SERVICES, LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/12/2013
-----------------------------------------------------
Last Update Date | 04/12/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2306 EDENBROOK DR
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23228-3010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-426-6323
-----------------------------------------------------
Fax | 804-794-6996
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 318 N ARCH RD SUITE 201
-----------------------------------------------------
City | NORTH CHESTERFIELD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23236-3567
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-426-6323
-----------------------------------------------------
Fax | 804-794-6996
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. DEXTER EDWARD WILLIAMS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 804-426-6323
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320800000X
-----------------------------------------------------
Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
-----------------------------------------------------
License Number | CRF-462
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------