Healthcare Provider Details

I. General information

NPI: 1215457254
Provider Name (Legal Business Name): BLAKE HOME HEALTH AGENCY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2017
Last Update Date: 08/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11815 FOUNTAIN WAY STE 300
NEWPORT NEWS VA
23606-4448
US

IV. Provider business mailing address

5709 S LABURNUM AVE
RICHMOND VA
23231-4420
US

V. Phone/Fax

Practice location:
  • Phone: 757-926-5241
  • Fax: 888-314-9510
Mailing address:
  • Phone: 804-545-1974
  • Fax: 888-314-9510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License NumberHCO171615
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License NumberHCO171615
License Number StateVA

VIII. Authorized Official

Name: MRS. DIONNE JACKSON
Title or Position: DIRECTOR
Credential:
Phone: 804-545-1974