Provider Demographics
NPI:1376083634
Name:DISTRICT THREE GOVERNMENTAL COOPERATIVE
Entity Type:Organization
Organization Name:DISTRICT THREE GOVERNMENTAL COOPERATIVE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:GUY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:276-783-8157
Mailing Address - Street 1:4453 LEE HWY
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:VA
Mailing Address - Zip Code:24354-4269
Mailing Address - Country:US
Mailing Address - Phone:276-783-8157
Mailing Address - Fax:276-783-3003
Practice Address - Street 1:4453 LEE HWY
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:VA
Practice Address - Zip Code:24354-4269
Practice Address - Country:US
Practice Address - Phone:276-783-8157
Practice Address - Fax:276-783-3003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-06
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0087402670Medicaid