MEDICARE: DIAMONDS IN THE ROUGH YOUTH AND FAMILY 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	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility	464-14-001	VA
2	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility	464-14-001	VA
3	251S00000X	Community/Behavioral Health Agency	464-05-001	VA

General Provider Information

NPI Number	:	1376728949
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIAMONDS IN THE ROUGH YOUTH AND FAMILY SERVICES, INC.

Provider Business Mailing Address
First Line	:	P O BOX 6386
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23230-3531
Country	:	US
Telephone Number	:	804-213-0140
Fax Number	:	804-213-0143

Provider Business Practice Location Address
First Line	:	4901 FITZHUGH AVE., STE. 200
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23230-3531
Country	:	US
Telephone Number	:	804-213-0140
Fax Number	:	804-213-0143

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MS. STEPHANIE LYNN DIXON
Credential	:
Telephone Number	:	804-213-0140

Provider Enumeration Date	:	01/02/2008
Last Update Date	:	05/25/2018

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