Provider Demographics
NPI:1477803070
Name:PIEDMONT REGIONAL COMMUNITY SERVICES BOARD
Entity Type:Organization
Organization Name:PIEDMONT REGIONAL COMMUNITY SERVICES BOARD
Other - Org Name:PIEDMONT HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:M
Authorized Official - Last Name:TOBIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:276-632-7128
Mailing Address - Street 1:24 CLAY STREET
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24112-2810
Mailing Address - Country:US
Mailing Address - Phone:276-632-7128
Mailing Address - Fax:276-632-0127
Practice Address - Street 1:26 BOOKER ROAD
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-2810
Practice Address - Country:US
Practice Address - Phone:276-632-2584
Practice Address - Fax:276-632-3110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-12
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA03801005320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC04131OtherMEDICARE GROUP NUMBER
VA004945221Medicaid