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General NPI Number Information
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NPI Number | 1366628760
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Entity Type | Organization
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Legal Business Name | FULL POTENTIAL YOUTH SERVICES
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Dates
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Enumeration Date | 01/15/2008
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Last Update Date | 01/15/2008
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Provider Practice Location Address
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Address Line | 18 TAYLOR RD
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City | RICHMOND
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State | VA
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Zip | 23223-5532
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Country | US
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Telephone | 804-222-3510
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Fax |
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Provider Business Mailing Address
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Address Line | 13107 LIBERTY POINT PL
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City | MIDLOTHIAN
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State | VA
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Zip | 23112-7000
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Country | US
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Telephone | 804-222-3510
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Fax |
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Authorized Official
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Title or Position | CHIEF ADMINISTRATION OFFICER
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Name | MR. JAMES BROADNAX HARRIS JR.
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Credential |
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Telephone | 804-837-4492
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | SS36507
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License Number State | VA
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