Provider Demographics
NPI:1043483415
Name:ALEXANDRIA COMMUNITY SERVICES BOARD
Entity type:Organization
Organization Name:ALEXANDRIA COMMUNITY SERVICES BOARD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GILMORE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:703-838-4455
Mailing Address - Street 1:2355A MILL RD
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22314-4608
Mailing Address - Country:US
Mailing Address - Phone:703-838-4455
Mailing Address - Fax:
Practice Address - Street 1:2355A MILL RD
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-4608
Practice Address - Country:US
Practice Address - Phone:703-838-4455
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ALEXANDRIA COMMUNITY SERVICES BOARD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-08
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101033931251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA10233662OtherAMERIGROUP CORP
VA0093OtherCAREFIRST BCBS
VA10233662OtherAMERIGROUP CORP