Provider Demographics
NPI:1790084804
Name:THE INDEPENDENT CAPACITY SYSTEM, INC.
Entity Type:Organization
Organization Name:THE INDEPENDENT CAPACITY SYSTEM, INC.
Other - Org Name:INDEPENDENT CAPACITY SYSTEM, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PASCAL
Authorized Official - Middle Name:
Authorized Official - Last Name:THEBAUD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-721-1720
Mailing Address - Street 1:PO BOX 3163
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23805-3163
Mailing Address - Country:US
Mailing Address - Phone:804-721-1720
Mailing Address - Fax:804-214-2177
Practice Address - Street 1:16015 CONTINENTAL BLVD
Practice Address - Street 2:
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834-5900
Practice Address - Country:US
Practice Address - Phone:804-721-1720
Practice Address - Fax:804-214-2177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-15
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA251S00000X, 320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities