Provider Demographics
NPI:1396022323
Name:JAMES BENTLEY TREATMENT PROGRAM
Entity Type:Organization
Organization Name:JAMES BENTLEY TREATMENT PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:PINNOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-399-4742
Mailing Address - Street 1:1520 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23704-3210
Mailing Address - Country:US
Mailing Address - Phone:757-399-4742
Mailing Address - Fax:
Practice Address - Street 1:1520 HIGH ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23704-3210
Practice Address - Country:US
Practice Address - Phone:757-399-4742
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-04
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA78203001251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA78203001Medicaid