=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376879411
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ATIBA YOUTH INTERVENTION SERVICES/DANVILLE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/25/2009
-----------------------------------------------------
Last Update Date | 10/25/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3401 WESTOVER DR STE A
-----------------------------------------------------
City | DANVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24541-5469
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-822-0084
-----------------------------------------------------
Fax | 434-822-0086
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7825 MIDLOTHIAN TPKE STE 112
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23235-5247
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-272-2277
-----------------------------------------------------
Fax | 804-272-2294
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MR. DONALD ANTHONY WHEELER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 804-272-2277
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 302F00000X
-----------------------------------------------------
Taxonomy Name | Exclusive Provider Organization
-----------------------------------------------------
License Number | 118105001
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------