Provider Demographics
NPI:1275800765
Name:DOMINION OUTPATIENT SERVICES
Entity Type:Organization
Organization Name:DOMINION OUTPATIENT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SERVICE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:HINES
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:804-272-2000
Mailing Address - Street 1:6767 FOREST HILL AVENUE
Mailing Address - Street 2:SUITE 307
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23225
Mailing Address - Country:US
Mailing Address - Phone:804-272-2000
Mailing Address - Fax:804-272-2030
Practice Address - Street 1:6767 FOREST HILL AVE
Practice Address - Street 2:SUITE 307
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23225-1856
Practice Address - Country:US
Practice Address - Phone:804-272-2000
Practice Address - Fax:804-272-2030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-28
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0904007163104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty