=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093234155
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEART FOUNDATION CO
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/10/2017
-----------------------------------------------------
Last Update Date | 09/10/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4950 JEFFERSON DAVIS HWY STE A
-----------------------------------------------------
City | NORTH CHESTERFIELD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23234-3957
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-833-8229
-----------------------------------------------------
Fax | 804-833-8229
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6108 JAHNKE RD
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23225-2639
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-833-8229
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MR. JAMIEL ADEYOLA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 804-833-8229
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number | 2038
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number | 2038
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------