Provider Demographics
NPI:1467448571
Name:GOOCHLAND POWHATAN COMMUNITY SERVICES
Entity Type:Organization
Organization Name:GOOCHLAND POWHATAN COMMUNITY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LESTER
Authorized Official - Middle Name:
Authorized Official - Last Name:SALTZBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-556-5400
Mailing Address - Street 1:PO BOX 189
Mailing Address - Street 2:
Mailing Address - City:GOOCHLAND
Mailing Address - State:VA
Mailing Address - Zip Code:23063-0189
Mailing Address - Country:US
Mailing Address - Phone:804-556-5400
Mailing Address - Fax:804-556-5403
Practice Address - Street 1:3058 RIVER RD W
Practice Address - Street 2:
Practice Address - City:GOOCHLAND
Practice Address - State:VA
Practice Address - Zip Code:23063-3202
Practice Address - Country:US
Practice Address - Phone:804-556-5400
Practice Address - Fax:804-556-5403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-23
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA207261QM0801X
343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004978561Medicaid
VA004945557Medicaid
VA004949927Medicaid
VA004948262Medicaid
VA004949919Medicaid
VA004948262Medicaid