Provider Demographics
NPI:1386809044
Name:CRIPPLED CHILDREN'S HOSPITAL
Entity type:Organization
Organization Name:CRIPPLED CHILDREN'S HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:G
Authorized Official - Last Name:WYATT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-321-7474
Mailing Address - Street 1:2924 BROOK RD
Mailing Address - Street 2:CHILDREN'S HOSPITAL THERAPY DEPT
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23220-1215
Mailing Address - Country:US
Mailing Address - Phone:804-321-7474
Mailing Address - Fax:804-228-5210
Practice Address - Street 1:321 B POPLAR DRIVE
Practice Address - Street 2:SUITE 4 CHILDREN'S HOSPITAL THERAPY CENTER
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23805
Practice Address - Country:US
Practice Address - Phone:804-321-7474
Practice Address - Fax:804-228-5210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-22
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAH1842261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004909976Medicaid