=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508132747
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. GARY A MCDANIEL JR.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/30/2012
-----------------------------------------------------
Last Update Date | 03/31/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3014 HEDRICK CT
-----------------------------------------------------
City | DANVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24540-1458
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-429-6052
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 102 MILES PL
-----------------------------------------------------
City | LYNCHBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24502-4538
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-429-5169
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320600000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------