MEDICARE: HIS SERVICE CENTER, 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	320800000X	Mental Illness Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1861096679
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HIS SERVICE CENTER, LLC

Provider Business Mailing Address
First Line	:	4808 CHATHAM GROVE PL
Second Line	:
City	:	NORTH CHESTERFIELD
State	:	VA
Zip	:	23236-1159
Country	:	US
Telephone Number	:	804-433-8247
Fax Number	:	804-800-2271

Provider Business Practice Location Address
First Line	:	4808 CHATHAM GROVE PL
Second Line	:
City	:	NORTH CHESTERFIELD
State	:	VA
Zip	:	23236-1159
Country	:	US
Telephone Number	:	804-433-8247
Fax Number	:	804-800-2271

Authorized Official
Title or Position	:	CLINICAL DIRECTOR
Name	:	MELANIE SUSANE JONES
Credential	:	LCSW
Telephone Number	:	804-433-8247

Provider Enumeration Date	:	11/23/2020
Last Update Date	:	11/23/2020

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