Provider Demographics
NPI:1629484514
Name:CHESTERFIELD COMMUNITY SERVICES BOARD-ICF MR GALLOWAY PLACE
Entity Type:Organization
Organization Name:CHESTERFIELD COMMUNITY SERVICES BOARD-ICF MR GALLOWAY PLACE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:
Authorized Official - Last Name:BURCHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-768-7220
Mailing Address - Street 1:6801 LUCY CORR CT
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23832-6657
Mailing Address - Country:US
Mailing Address - Phone:804-748-1227
Mailing Address - Fax:804-717-6659
Practice Address - Street 1:6801 LUCY CORR CT
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23832-6657
Practice Address - Country:US
Practice Address - Phone:804-748-1227
Practice Address - Fax:804-717-6659
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-11
Last Update Date:2014-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004945352Medicaid
VA004945352Medicaid