Provider Demographics
NPI:1700486099
Name:CARDINAL CARE PSYCHIATRIC SERVICES
Entity type:Organization
Organization Name:CARDINAL CARE PSYCHIATRIC SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:NAOMI
Authorized Official - Middle Name:
Authorized Official - Last Name:MYRICK
Authorized Official - Suffix:
Authorized Official - Credentials:MSN,APRN,PMHNP-BC
Authorized Official - Phone:757-653-4131
Mailing Address - Street 1:3600 W BROAD ST UNIT 536
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23230-4948
Mailing Address - Country:US
Mailing Address - Phone:757-653-4131
Mailing Address - Fax:
Practice Address - Street 1:3600 W BROAD ST UNIT 536
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23230-4948
Practice Address - Country:US
Practice Address - Phone:757-653-4131
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-27
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1700430733Medicaid