Provider Demographics
NPI:1013320712
Name:SOUTHEASTERN VIRGINIA AREAWIDE MODEL PROGRAM
Entity Type:Organization
Organization Name:SOUTHEASTERN VIRGINIA AREAWIDE MODEL PROGRAM
Other - Org Name:SENIOR SERVICES OF SOUTHEASTERN VIRGINIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:N
Authorized Official - Last Name:SKIRVEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-222-4510
Mailing Address - Street 1:6350 CENTER DR
Mailing Address - Street 2:SUITE101
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-4107
Mailing Address - Country:US
Mailing Address - Phone:757-461-9481
Mailing Address - Fax:757-461-1068
Practice Address - Street 1:6350 CENTER DR
Practice Address - Street 2:SUITE101
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-4107
Practice Address - Country:US
Practice Address - Phone:757-461-9481
Practice Address - Fax:757-461-1068
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-10
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1060267354302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0160267354Medicaid
VA0161745051Medicaid