Provider Demographics
NPI:1689928996
Name:WESTERN TIDEWATER COMMUNITY SERVICES BOARD
Entity Type:Organization
Organization Name:WESTERN TIDEWATER COMMUNITY SERVICES BOARD
Other - Org Name:VINCE'S PLACE/CHASE'S WAY ICF/IID
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DEMETRIOS
Authorized Official - Middle Name:
Authorized Official - Last Name:PERATSAKIS
Authorized Official - Suffix:
Authorized Official - Credentials:PD, MS, LPC
Authorized Official - Phone:757-255-7133
Mailing Address - Street 1:7025 HARBOUR VIEW BLVD STE 119
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23435-2762
Mailing Address - Country:US
Mailing Address - Phone:757-966-2805
Mailing Address - Fax:757-673-2586
Practice Address - Street 1:4373 PRUDEN BOULEVARD
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434
Practice Address - Country:US
Practice Address - Phone:757-255-7127
Practice Address - Fax:757-255-7139
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-08
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA08401005315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities