NPIMap

Organization Active NPI

Western Tidewater Community Services Board

  • Intellectual Disabilities Intermediate Care Facility
  • Suffolk, VA
National Provider Identifier
1689928996
Registry record updated Jan 29, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Intellectual Disabilities Intermediate Care FacilityTaxonomy code 315P00000X
License
08401005 Issued in VA
Legal business name
WESTERN TIDEWATER COMMUNITY SERVICES BOARD
Practice address
4373 Pruden Boulevard
Suffolk, VA 23434
Phone
(757) 255-7127
Fax
(757) 255-7139
NPI assigned
Nov 8, 2012
Last updated
Jan 29, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 29, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Demetrios Peratsakis, PD, MS, LPC
Title
Executive Director
Phone
(757) 255-7133

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Intellectual Disabilities Intermediate Care Facility 315P00000X 08401005 VA Primary

Addresses

Primary practice location

4373 Pruden Boulevard
Suffolk, VA 23434

Mailing address

7025 Harbour View Blvd Ste 119
Suffolk, VA 23435-2762
Phone (757) 966-2805

Other names 1

  • Vince's Place/Chase's Way ICF/IID Other name

National Provider Directory

National Provider Directory
Tax ID family
Western Tidewater Community Services Board8 organizations share this tax ID, including this one

Other organizations with this tax ID 7

Organizations that report the same tax identification number in the National Provider Directory.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1352332800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1706486400000",
    "number": "1689928996",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "7025 HARBOUR VIEW BLVD STE 119",
            "city": "SUFFOLK",
            "state": "VA",
            "postal_code": "234352762",
            "telephone_number": "757-966-2805",
            "fax_number": "757-673-2586"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4373 PRUDEN BOULEVARD",
            "city": "SUFFOLK",
            "state": "VA",
            "postal_code": "23434",
            "telephone_number": "757-255-7127",
            "fax_number": "757-255-7139"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WESTERN TIDEWATER COMMUNITY SERVICES BOARD",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-11-08",
        "last_updated": "2024-01-29",
        "certification_date": "2024-01-29",
        "status": "A",
        "authorized_official_last_name": "PERATSAKIS",
        "authorized_official_first_name": "DEMETRIOS",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "757-255-7133",
        "authorized_official_credential": "PD, MS, LPC"
    },
    "taxonomies": [
        {
            "code": "315P00000X",
            "taxonomy_group": "",
            "desc": "Intermediate Care Facility, Intellectual Disabilities",
            "state": "VA",
            "license": "08401005",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Vince's Place/Chase's Way ICF/IID",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Suffolk, VA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 29, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.