Basic Information
| Provider Information | |||||||||
| NPI: | 1477803070 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PIEDMONT REGIONAL COMMUNITY SERVICES BOARD | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PIEDMONT HOME | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24 CLAY STREET | ||||||||
| Address2: | |||||||||
| City: | MARTINSVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 241122810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2766327128 | ||||||||
| FaxNumber: | 2766320127 | ||||||||
| Practice Location | |||||||||
| Address1: | 26 BOOKER ROAD | ||||||||
| Address2: | |||||||||
| City: | MARTINSVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 241122810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2766322584 | ||||||||
| FaxNumber: | 2766323110 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2012 | ||||||||
| LastUpdateDate: | 09/12/2012 | ||||||||
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| AuthorizedOfficialLastName: | TOBIN | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2766327128 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320600000X | 03801005 | VA | Y | Residential Treatment Facilities | Residential Treatment Facility, Mental Retardation and/or Developmental Disabilities |
ID Information
| ID | Type | State | Issuer | Description | C04131 | 01 | VA | MEDICARE GROUP NUMBER | OTHER | 004945221 | 05 | VA | MEDICAID |