Provider Demographics
NPI:1821657719
Name:HAMPTON-NEWPORT NEWS COMMUNITY SERVICES BOARD
Entity Type:Organization
Organization Name:HAMPTON-NEWPORT NEWS COMMUNITY SERVICES BOARD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING/PROCUREMENT COORDINAT
Authorized Official - Prefix:
Authorized Official - First Name:YAISA
Authorized Official - Middle Name:ONIKA
Authorized Official - Last Name:GOODWIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-788-0065
Mailing Address - Street 1:300 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-1765
Mailing Address - Country:US
Mailing Address - Phone:757-788-0300
Mailing Address - Fax:
Practice Address - Street 1:1421 ABERDEEN RD
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-4027
Practice Address - Country:US
Practice Address - Phone:757-251-2244
Practice Address - Fax:757-224-4950
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HAMPTON-NEWPORT NEWS COMMUNITY SERVICES BOARD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-06-13
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1659424448Medicaid