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General NPI Number Information
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NPI Number | 1235674151
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Entity Type | Organization
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Legal Business Name | NANAS HOUSE NEWPORT NEWS
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Dates
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Enumeration Date | 01/01/2017
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Last Update Date | 01/01/2017
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Provider Practice Location Address
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Address Line | 2706 MARSHALL AVE
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City | NEWPORT NEWS
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State | VA
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Zip | 23607-4120
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Country | US
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Telephone | 757-247-6472
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Fax |
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Provider Business Mailing Address
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Address Line | 2706 MARSHALL AVE
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City | NEWPORT NEWS
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State | VA
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Zip | 23607-4120
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | FOUNDER
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Name | BEN TYNES
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Credential | MBA/CPHIMS
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Telephone | 240-281-7653
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number | 2370-02-001
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License Number State | VA
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