Provider Demographics
NPI:1083078935
Name:RURAL INFANT SERVICES PROGRAM
Entity Type:Organization
Organization Name:RURAL INFANT SERVICES PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CASE MANAGER/CARE COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JULIA
Authorized Official - Middle Name:HUNDLEY
Authorized Official - Last Name:SELF
Authorized Official - Suffix:
Authorized Official - Credentials:BSW
Authorized Official - Phone:804-761-4131
Mailing Address - Street 1:535372B OLD VIRGINIA STREET
Mailing Address - Street 2:
Mailing Address - City:URBANNA
Mailing Address - State:VA
Mailing Address - Zip Code:23175
Mailing Address - Country:US
Mailing Address - Phone:804-761-4131
Mailing Address - Fax:
Practice Address - Street 1:535372 OLD VIRGINIA STREET
Practice Address - Street 2:B
Practice Address - City:URBANNA
Practice Address - State:VA
Practice Address - Zip Code:23175
Practice Address - Country:US
Practice Address - Phone:804-761-4131
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MIDDLE PENINSULA NORTHERN NECK COMMUNITY SERVICES BOARD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-04-07
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAT67028145251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management