Provider Demographics
NPI:1245422989
Name:EASTER SEALS VIRGINIA
Entity Type:Organization
Organization Name:EASTER SEALS VIRGINIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAZELBAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-287-1007
Mailing Address - Street 1:8003 FRANKLIN FARMS DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23229-5107
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:900 CAMP EASTER SEALS RD
Practice Address - Street 2:
Practice Address - City:NEW CASTLE
Practice Address - State:VA
Practice Address - Zip Code:24127-9566
Practice Address - Country:US
Practice Address - Phone:540-864-5750
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-16
Last Update Date:2007-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA170325OtherANTHEM
VA499105Medicare PIN