MEDICARE: SIMPLE INTERVENTION, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency	2548	VA

General Provider Information

NPI Number	:	1043612104
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SIMPLE INTERVENTION, LLC

Provider Business Mailing Address
First Line	:	PO BOX 1330
Second Line	:
City	:	CHESTERFIELD
State	:	VA
Zip	:	23832-9103
Country	:	US
Telephone Number	:	804-621-4034
Fax Number	:	804-200-5413

Provider Business Practice Location Address
First Line	:	9850 LORI RD
Second Line	:	SUITE 101
City	:	CHESTERFIELD
State	:	VA
Zip	:	23832-6758
Country	:	US
Telephone Number	:	804-621-4034
Fax Number	:	804-621-4091

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. BRANDON C HUDSON
Credential	:	BS
Telephone Number	:	804-621-4034

Provider Enumeration Date	:	09/20/2014
Last Update Date	:	02/06/2017

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