Provider Demographics
NPI:1578798849
Name:EAST END ACADEMY INC SOUTHSIDE
Entity Type:Organization
Organization Name:EAST END ACADEMY INC SOUTHSIDE
Other - Org Name:EAST END ACADEMY INC SOUTHSIDE
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:RUBY
Authorized Official - Middle Name:
Authorized Official - Last Name:ELEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-275-7498
Mailing Address - Street 1:2607 COLONIAL AVE
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23517-1227
Mailing Address - Country:US
Mailing Address - Phone:757-275-7498
Mailing Address - Fax:757-375-7561
Practice Address - Street 1:2607 COLONIAL AVENUE
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23517
Practice Address - Country:US
Practice Address - Phone:757-275-7498
Practice Address - Fax:757-275-7561
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EAST END ACADEMY INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-05-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA320261QM0801X
VA261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA23517Medicaid