Provider Demographics
NPI:1851866479
Name:AMETHYST CARE GROUP INC
Entity type:Organization
Organization Name:AMETHYST CARE GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:VAN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:757-754-5239
Mailing Address - Street 1:392 S NEWTOWN RD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-6202
Mailing Address - Country:US
Mailing Address - Phone:757-754-5239
Mailing Address - Fax:
Practice Address - Street 1:6253 AUBURN DR
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-3714
Practice Address - Country:US
Practice Address - Phone:757-756-4506
Practice Address - Fax:866-248-3114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-10
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities