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General NPI Number Information
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NPI Number | 1548495708
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Entity Type | Organization
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Legal Business Name | INTENSIVE COMMUNITY OUTREACH SERVICES
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Dates
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Enumeration Date | 05/18/2009
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Last Update Date | 05/18/2009
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Provider Practice Location Address
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Address Line | 1524 MERRIMAC TRAIL SUITE J
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City | WILIAMSBURG
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State | VA
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Zip | 23815
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Country | US
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Telephone | 804-521-4327
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Fax |
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Provider Business Mailing Address
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Address Line | 501 E. FRANKLIN STREET SUITE 516
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City | RICHMOND
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State | VA
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Zip | 23219
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Country | US
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Telephone | 804-521-4327
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. BERNARD LAMONT HEYWARD
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Credential |
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Telephone | 804-551-4155
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305S00000X
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Taxonomy Name | Point of Service
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License Number | 07313155018008081414
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License Number State | VA
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