Provider Demographics
NPI:1114027521
Name:COMMONWEALTH OF VIRGINIA DEPARTMENT OF BEHAVI
Entity Type:Organization
Organization Name:COMMONWEALTH OF VIRGINIA DEPARTMENT OF BEHAVI
Other - Org Name:EASTERN STATE HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HOSPITAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:L
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:757-253-5241
Mailing Address - Street 1:4601 IRONBOUND RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23188-2652
Mailing Address - Country:US
Mailing Address - Phone:757-253-5241
Mailing Address - Fax:757-253-5065
Practice Address - Street 1:4601 IRONBOUND RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-2652
Practice Address - Country:US
Practice Address - Phone:757-253-5241
Practice Address - Fax:757-253-5065
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMONWEALTH OF VIRGINIA DEPARTMENT OF BEHAVIORAL HEALTH AN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-25
Last Update Date:2011-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310500000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004966244Medicaid