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General NPI Number Information
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NPI Number | 1720429889
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Entity Type | Organization
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Legal Business Name | KEY INDEPENDENT DEVELOPMENT SERVICES
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Dates
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Enumeration Date | 07/17/2013
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Last Update Date | 07/17/2013
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Provider Practice Location Address
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Address Line | 509 N HENRY ST
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City | RICHMOND
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State | VA
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Zip | 23220-3924
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Country | US
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Telephone | 804-909-1762
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Fax |
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Provider Business Mailing Address
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Address Line | 509 N HENRY ST
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City | RICHMOND
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State | VA
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Zip | 23220-3924
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Country | US
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Telephone | 804-909-1762
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Fax |
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Authorized Official
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Title or Position | PROGRAM DIRECTOR
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Name | MALCOLM ISAIAH MOODY
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Credential | MPA, B.S.
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Telephone | 804-909-1762
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 2105
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License Number State | VA
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