Provider Demographics
NPI:1407993777
Name:DOMINION YOUTH SERVICES
Entity Type:Organization
Organization Name:DOMINION YOUTH SERVICES
Other - Org Name:DOMINION YOUTH SERVICES RESIDENTIAL LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF RESIDENTIAL
Authorized Official - Prefix:MR
Authorized Official - First Name:GL
Authorized Official - Middle Name:
Authorized Official - Last Name:PULLIAM
Authorized Official - Suffix:JR
Authorized Official - Credentials:MS
Authorized Official - Phone:804-285-9838
Mailing Address - Street 1:PO BOX 70296
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23255-0296
Mailing Address - Country:US
Mailing Address - Phone:804-285-9838
Mailing Address - Fax:804-285-9839
Practice Address - Street 1:2419 FON DU LAC RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23229
Practice Address - Country:US
Practice Address - Phone:804-440-7074
Practice Address - Fax:804-440-7075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA406-14-001320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness