=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679267892
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRIGHT THERAPEUTIC SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2023
-----------------------------------------------------
Last Update Date | 06/08/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1511 RODMAN AVE
-----------------------------------------------------
City | PORTSMOUTH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23707-4321
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-995-8829
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1511 RODMAN AVE
-----------------------------------------------------
City | PORTSMOUTH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23707-4321
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | TANMARON BRANDON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 757-835-1506
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------