=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447550660
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UPSIDE TO YOUTH DEVELOPMENT, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/22/2010
-----------------------------------------------------
Last Update Date | 10/22/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 320 E BROADWAY SUITE 205
-----------------------------------------------------
City | HOPEWELL
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23860-2812
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-541-7894
-----------------------------------------------------
Fax | 804-541-7895
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 320 E BROADWAY SUITE 205
-----------------------------------------------------
City | HOPEWELL
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23860-2812
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-541-7894
-----------------------------------------------------
Fax | 804-541-7895
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF EXECUTIVE OFFICER
-----------------------------------------------------
Name | MR. BRANDON C HUDSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 804-541-7894
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 1082
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------