MEDICARE: GIFTED HANDS & HEARTS SPONSORED 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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1710583224
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GIFTED HANDS & HEARTS SPONSORED RESIDENTIAL SERVICES LLC

Provider Business Mailing Address
First Line	:	8014 MIDLOTHIAN TPKE STE 309
Second Line	:
City	:	NORTH CHESTERFIELD
State	:	VA
Zip	:	23235-5291
Country	:	US
Telephone Number	:	804-967-4221
Fax Number	:

Provider Business Practice Location Address
First Line	:	8014 MIDLOTHIAN TPKE STE 309
Second Line	:
City	:	NORTH CHESTERFIELD
State	:	VA
Zip	:	23235-5291
Country	:	US
Telephone Number	:	804-967-4221
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MRS. HYLA BLONDELL JOHNSON
Credential	:
Telephone Number	:	804-967-4221

Provider Enumeration Date	:	12/09/2020
Last Update Date	:	12/09/2020

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