Basic Information
| Provider Information | |||||||||
| NPI: | 1184823155 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRINCE WILLIAM COUNTY EARLY INTERVENTION PROGRAM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7969 ASHTON AVE | ||||||||
| Address2: | |||||||||
| City: | MANASSAS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201092885 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7037927800 | ||||||||
| FaxNumber: | 7037925699 | ||||||||
| Practice Location | |||||||||
| Address1: | 7969 ASHTON AVE | ||||||||
| Address2: | |||||||||
| City: | MANASSAS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201092885 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7037927800 | ||||||||
| FaxNumber: | 7037925699 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2007 | ||||||||
| LastUpdateDate: | 07/11/2007 | ||||||||
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| AuthorizedOfficialLastName: | GEIB | ||||||||
| AuthorizedOfficialFirstName: | TOM | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7037927800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PRINCE WILLIAM COUNTY COMMUNITY SERVICES BOARD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 187835 | 01 | VA | ANTHEM BLUE CROSS BLUE SH | OTHER | 187839 | 01 | VA | ANTHEM BLUE CROSS BLUE SH | OTHER | 187840 | 01 | VA | ANTHEM BLUE CROSS BLUE SH | OTHER |