Provider Demographics
NPI:1275762700
Name:AMIKIDS VIRGINIA WILDERNESS
Entity Type:Organization
Organization Name:AMIKIDS VIRGINIA WILDERNESS
Other - Org Name:VIRGINIA WILDERNESS INSTITUTE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:OTELIA
Authorized Official - Middle Name:REBECCA
Authorized Official - Last Name:ENGLAND
Authorized Official - Suffix:
Authorized Official - Credentials:MED
Authorized Official - Phone:276-498-7032
Mailing Address - Street 1:PO BOX 613
Mailing Address - Street 2:
Mailing Address - City:OAKWOOD
Mailing Address - State:VA
Mailing Address - Zip Code:24631-0613
Mailing Address - Country:US
Mailing Address - Phone:276-498-7032
Mailing Address - Fax:276-498-4863
Practice Address - Street 1:3477 WILDERNESS ROAD
Practice Address - Street 2:
Practice Address - City:OAKWOOD
Practice Address - State:VA
Practice Address - Zip Code:24631
Practice Address - Country:US
Practice Address - Phone:276-498-7032
Practice Address - Fax:276-498-4863
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-06
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VACO-437-09322D00000X, 323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children