MEDICARE: DOMINION YOUTH SERVICES

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	320800000X	Mental Illness Community Based Residential Treatment Facility	SS-284-06	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	SS-284-06	OTHER	VA	DSS LICENSE

General Provider Information

NPI Number	:	1245369750
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DOMINION YOUTH SERVICES

Provider Business Mailing Address
First Line	:	PO BOX 70296
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23255-0296
Country	:	US
Telephone Number	:	804-285-9838
Fax Number	:	804-285-9839

Provider Business Practice Location Address
First Line	:	2407 DUMBARTON RD
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23228-5909
Country	:	US
Telephone Number	:	804-553-0595
Fax Number	:	804-553-0596

Authorized Official
Title or Position	:	DIRECTOR OF RESIDENTIAL
Name	:	MR. GL PULLIAM JR.
Credential	:	MS
Telephone Number	:	804-285-9838

Provider Enumeration Date	:	03/02/2007
Last Update Date	:	08/22/2020

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Directions to “DOMINION YOUTH SERVICES ” Practice Location

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