Provider Demographics
NPI:1841258589
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:RN, MS
Authorized Official - Phone:804-321-7474
Mailing Address - Street 1:2924 BROOK RD
Mailing Address - Street 2:
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:804-321-2728
Practice Address - Street 1:2924 BROOK RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23220-1215
Practice Address - Country:US
Practice Address - Phone:804-321-7474
Practice Address - Fax:804-321-2728
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2009-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAH1627282NC2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC2000XHospitalsGeneral Acute Care HospitalChildren
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004909976Medicaid
VAC09422OtherMEDICARE PART B
VA004939972Medicaid
VA004960777Medicaid
VA004909976Medicaid