Healthcare Provider Details

I. General information

NPI: 1700115912
Provider Name (Legal Business Name): HEAVENLY WORKS HOME HEALTH CARE SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2009
Last Update Date: 12/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5040 VIRGINIA BEACH BLVD 103
VIRGINIA BCH VA
23462-6637
US

IV. Provider business mailing address

5040 VIRGINIA BEACH BLVD 103
VIRGINIA BCH VA
23462-6637
US

V. Phone/Fax

Practice location:
  • Phone: 757-718-7355
  • Fax: 757-961-8744
Mailing address:
  • Phone: 757-718-7355
  • Fax: 757-961-8744

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number128291
License Number StateVA

VIII. Authorized Official

Name: MS. WANDA RENNE RIDDICK
Title or Position: NURSE ADMINISTRATOR
Credential: 99 CREDITS
Phone: 757-717-1785