Provider Demographics
NPI:1366628760
Name:FULL POTENTIAL YOUTH SERVICES
Entity Type:Organization
Organization Name:FULL POTENTIAL YOUTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF ADMINISTRATION OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:BROADNAX
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:804-837-4492
Mailing Address - Street 1:13107 LIBERTY POINT PL
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-7000
Mailing Address - Country:US
Mailing Address - Phone:804-222-3510
Mailing Address - Fax:
Practice Address - Street 1:18 TAYLOR RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23223-5532
Practice Address - Country:US
Practice Address - Phone:804-222-3510
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-15
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VASS36507251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health