MEDICARE: PATRICK HENRY BOYS AND GIRLS PLANTATION, 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	101YP2500X	Professional Counselor	0701003238	VA
2	101YP2500X	Professional Counselor	0701003872	VA
3	101YP2500X	Professional Counselor	0701003730	VA

General Provider Information

NPI Number	:	1710185897
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PATRICK HENRY BOYS AND GIRLS PLANTATION, INC

Provider Business Mailing Address
First Line	:	1617A ENTERPRISE DR
Second Line	:
City	:	LYNCHBURG
State	:	VA
Zip	:	24502-5797
Country	:	US
Telephone Number	:	434-239-4949
Fax Number	:	434-239-4955

Provider Business Practice Location Address
First Line	:	1617A ENTERPRISE DR
Second Line	:
City	:	LYNCHBURG
State	:	VA
Zip	:	24502-5797
Country	:	US
Telephone Number	:	434-239-4949
Fax Number	:	434-239-4955

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. JASON WATSON
Credential	:
Telephone Number	:	434-376-2006

Provider Enumeration Date	:	07/10/2007
Last Update Date	:	07/10/2007

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