=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760163141
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NYO COMMUNITY SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2023
-----------------------------------------------------
Last Update Date | 07/27/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 144 BUSINESS PARK DR STE 202B
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23462-6527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-799-4750
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 144 BUSINESS PARK DR STE 202B
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23462-6527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-799-4750
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MICHAEL CLEMONS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 757-799-4750
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------