Provider Demographics
NPI:1134596224
Name:PENINSULA AGENCY ON AGING
Entity type:Organization
Organization Name:PENINSULA AGENCY ON AGING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:S
Authorized Official - Last Name:MASSEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-873-0541
Mailing Address - Street 1:739 THIMBLE SHOALS BLVD
Mailing Address - Street 2:BUILDING 1000, STE 1006
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-3562
Mailing Address - Country:US
Mailing Address - Phone:757-873-0541
Mailing Address - Fax:757-873-1437
Practice Address - Street 1:739 THIMBLE SHOALS BLVD
Practice Address - Street 2:BUILDING 1000, STE 1006
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-3562
Practice Address - Country:US
Practice Address - Phone:757-873-0541
Practice Address - Fax:757-873-1437
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-25
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No251V00000XAgenciesVoluntary or Charitable
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0155129973OtherAPI