Healthcare Provider Details

I. General information

NPI: 1598572109
Provider Name (Legal Business Name): KINDHEARTED SUPPORTIVE SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2024
Last Update Date: 12/17/2024
Certification Date: 12/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4665 HAYGOOD RD STE 401
VIRGINIA BEACH VA
23455-5443
US

IV. Provider business mailing address

4665 HAYGOOD RD STE 401
VIRGINIA BEACH VA
23455-5443
US

V. Phone/Fax

Practice location:
  • Phone: 757-404-9744
  • Fax: 757-301-5506
Mailing address:
  • Phone: 757-404-9744
  • Fax: 757-301-5506

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: KIMYATTA RIVERS
Title or Position: OWNER
Credential:
Phone: 757-996-0665