MEDICARE: INTERCEPT YOUTH SERVICES, INC.

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	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility	295-14-011	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1275634610
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTERCEPT YOUTH SERVICES, INC.

Provider Business Mailing Address
First Line	:	5511 STAPLES MILL RD
Second Line	:	SUITE 102
City	:	RICHMOND
State	:	VA
Zip	:	23228-5445
Country	:	US
Telephone Number	:	804-864-1320
Fax Number	:	804-864-1323

Provider Business Practice Location Address
First Line	:	2129 S PROVIDENCE RD
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23236-2160
Country	:	US
Telephone Number	:	804-249-3350
Fax Number	:	804-249-3352

Authorized Official
Title or Position	:	DIR OF ACCOUNTING & ADMINISTRATION
Name	:	DAVID RANDOLPH GRAHAM
Credential	:
Telephone Number	:	804-864-1320

Provider Enumeration Date	:	09/26/2006
Last Update Date	:	09/24/2020

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