Healthcare Provider Details

I. General information

NPI: 1093234155
Provider Name (Legal Business Name): HEART FOUNDATION CO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2017
Last Update Date: 09/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4950 JEFFERSON DAVIS HWY STE A
NORTH CHESTERFIELD VA
23234-3957
US

IV. Provider business mailing address

6108 JAHNKE RD
RICHMOND VA
23225-2639
US

V. Phone/Fax

Practice location:
  • Phone: 804-833-8229
  • Fax: 804-833-8229
Mailing address:
  • Phone: 804-833-8229
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number2038
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number2038
License Number StateVA

VIII. Authorized Official

Name: MR. JAMIEL ADEYOLA
Title or Position: MANAGER
Credential:
Phone: 804-833-8229