Provider Demographics
NPI:1639987530
Name:YOUR BUSINESS CCC
Entity type:Organization
Organization Name:YOUR BUSINESS CCC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:WHITNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-347-0703
Mailing Address - Street 1:424 MARKET ST STE 100
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-5249
Mailing Address - Country:US
Mailing Address - Phone:757-347-0703
Mailing Address - Fax:
Practice Address - Street 1:424 MARKET ST STE 100
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-5249
Practice Address - Country:US
Practice Address - Phone:757-347-0703
Practice Address - Fax:757-276-6514
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:YOUR BUSINESS CCC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-12-23
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1922695592Medicaid