MEDICARE: ATIBA YOUTH INTERVENTION SERVICSE

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	1181	VA

General Provider Information

NPI Number	:	1477719144
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ATIBA YOUTH INTERVENTION SERVICSE

Provider Business Mailing Address
First Line	:	7825 MIDLOTHIAN TPKE
Second Line	:	SUITE 112
City	:	RICHMOND
State	:	VA
Zip	:	23235-5247
Country	:	US
Telephone Number	:	804-272-2277
Fax Number	:

Provider Business Practice Location Address
First Line	:	7825 MIDLOTHIAN TPKE
Second Line	:	SUITE 112
City	:	RICHMOND
State	:	VA
Zip	:	23235-5247
Country	:	US
Telephone Number	:	804-272-2277
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. DONALD ANTHONY WHEELER
Credential	:
Telephone Number	:	804-272-2277

Provider Enumeration Date	:	08/01/2008
Last Update Date	:	08/01/2008

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