Provider Demographics
NPI:1376879411
Name:ATIBA YOUTH INTERVENTION SERVICES/DANVILLE LLC
Entity Type:Organization
Organization Name:ATIBA YOUTH INTERVENTION SERVICES/DANVILLE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:WHEELER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-272-2277
Mailing Address - Street 1:7825 MIDLOTHIAN TPKE STE 112
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23235-5247
Mailing Address - Country:US
Mailing Address - Phone:804-272-2277
Mailing Address - Fax:804-272-2294
Practice Address - Street 1:3401 WESTOVER DR STE A
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24541-5469
Practice Address - Country:US
Practice Address - Phone:434-822-0084
Practice Address - Fax:434-822-0086
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ATIBA YOUTH INTERVENTION SERVICES LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-10-25
Last Update Date:2009-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA118105001302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization