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General NPI Number Information
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NPI Number | 1093794877
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Entity Type | Organization
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Legal Business Name | SOUTHSIDE VIRGINIA TRANINNG CENTER
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Dates
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Enumeration Date | 01/11/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 26317 W WASHINGTON ST
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City | PETERSBURG
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State | VA
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Zip | 23803-0030
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Country | US
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Telephone | 804-524-7209
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Fax | 804-524-7228
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Provider Business Mailing Address
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Address Line | PO BOX 4030
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City | PETERSBURG
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State | VA
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Zip | 23803-0030
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Country | US
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Telephone | 804-524-7209
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Fax | 804-524-7228
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Authorized Official
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Title or Position | FACILITY DIRECTOR
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Name | DR. JOHN A. HOLLAND JR.
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Credential | MD
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Telephone | 804-524-7209
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320600000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
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License Number | 28892
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License Number State | VA
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