=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023579711
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OPEN HEARTS RESIDENTIAL SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2019
-----------------------------------------------------
Last Update Date | 07/24/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1426 KEMP BRIDGE DR
-----------------------------------------------------
City | CHESAPEAKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23320-5057
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-547-0372
-----------------------------------------------------
Fax | 757-436-3561
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1426 KEMP BRIDGE DR
-----------------------------------------------------
City | CHESAPEAKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23320-5057
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-232-7807
-----------------------------------------------------
Fax | 757-436-3561
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF EXECUITVE OFFICER
-----------------------------------------------------
Name | TRACY BRADSHAW
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 757-547-0372
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253J00000X
-----------------------------------------------------
Taxonomy Name | Foster Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------