=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790084804
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE INDEPENDENT CAPACITY SYSTEM, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/15/2011
-----------------------------------------------------
Last Update Date | 03/15/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16015 CONTINENTAL BLVD
-----------------------------------------------------
City | COLONIAL HEIGHTS
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23834-5900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-721-1720
-----------------------------------------------------
Fax | 804-214-2177
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3163
-----------------------------------------------------
City | PETERSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23805-3163
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-721-1720
-----------------------------------------------------
Fax | 804-214-2177
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MR. PASCAL THEBAUD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 804-721-1720
-----------------------------------------------------
=====================================================
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 | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------