Provider Demographics
NPI:1154411510
Name:EASTERN SHORE COMMUNITY MH MR SAS SERVICES BOARD
Entity type:Organization
Organization Name:EASTERN SHORE COMMUNITY MH MR SAS SERVICES BOARD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:A
Authorized Official - Last Name:CANNON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-442-3636
Mailing Address - Street 1:PO BOX 453
Mailing Address - Street 2:
Mailing Address - City:NASSAWADOX
Mailing Address - State:VA
Mailing Address - Zip Code:23413-0453
Mailing Address - Country:US
Mailing Address - Phone:757-442-3636
Mailing Address - Fax:
Practice Address - Street 1:19056 GREENBUSH RD
Practice Address - Street 2:
Practice Address - City:PARKSLEY
Practice Address - State:VA
Practice Address - Zip Code:23421
Practice Address - Country:US
Practice Address - Phone:757-665-1260
Practice Address - Fax:757-665-4184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC05541Medicare PIN
VAC02848Medicare PIN