MEDICARE: HEART TO HEART RESIDENTIAL SERVICES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility	1821-01-001	VA

General Provider Information

NPI Number	:	1093141517
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEART TO HEART RESIDENTIAL SERVICES LLC

Provider Business Mailing Address
First Line	:	6012 MOONLIGHT DR
Second Line	:
City	:	NORTH CHESTERFIELD
State	:	VA
Zip	:	23234-4620
Country	:	US
Telephone Number	:	804-833-0873
Fax Number	:

Provider Business Practice Location Address
First Line	:	2115 N WHITEHILL DR
Second Line	:
City	:	PETERSBURG
State	:	VA
Zip	:	23803-3731
Country	:	US
Telephone Number	:	804-833-0873
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATIVE DIRECTOR
Name	:	SHAKIA HAYES-CONWAY
Credential	:
Telephone Number	:	804-833-0873

Provider Enumeration Date	:	09/16/2013
Last Update Date	:	09/16/2013

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