Basic Information
| Provider Information | |||||||||
| NPI: | 1245547264 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MIDDLE PENINSULA NORTHERN NECK COMMUNITY SERVICES BOARD | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 40 | ||||||||
| Address2: | |||||||||
| City: | SALUDA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 231490040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8047585250 | ||||||||
| FaxNumber: | 8047585183 | ||||||||
| Practice Location | |||||||||
| Address1: | 5372B OLD VIRGINIA STREET | ||||||||
| Address2: | |||||||||
| City: | URBANNA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 23175 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8047585250 | ||||||||
| FaxNumber: | 8047585183 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2010 | ||||||||
| LastUpdateDate: | 09/13/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TAYLOR | ||||||||
| AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
| AuthorizedOfficialMiddleName: | MIDDLETON | ||||||||
| AuthorizedOfficialTitleorPosition: | CARE COORDINATOR/CASE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8047585250 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | Q.M.R.P. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | 171M00000X | VA | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 49-7813-7 | 05 | VA | MEDICAID |