Provider Demographics
NPI:1558603688
Name:HARVEST OUTREACH CENTER
Entity Type:Organization
Organization Name:HARVEST OUTREACH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CARRINGTON
Authorized Official - Middle Name:
Authorized Official - Last Name:MENZEL
Authorized Official - Suffix:
Authorized Official - Credentials:M ED QMHP
Authorized Official - Phone:434-944-9807
Mailing Address - Street 1:410 MADDOX RD
Mailing Address - Street 2:
Mailing Address - City:GLADYS
Mailing Address - State:VA
Mailing Address - Zip Code:24554-3030
Mailing Address - Country:US
Mailing Address - Phone:434-283-5340
Mailing Address - Fax:
Practice Address - Street 1:410 MADDOX RD
Practice Address - Street 2:
Practice Address - City:GLADYS
Practice Address - State:VA
Practice Address - Zip Code:24554-3030
Practice Address - Country:US
Practice Address - Phone:434-283-5340
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-27
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701002055302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization