=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952751117
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OPEN HEART SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2016
-----------------------------------------------------
Last Update Date | 06/20/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 813 FORREST DR STE C
-----------------------------------------------------
City | NEWPORT NEWS
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23606-4513
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-240-4180
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 813 FORREST DR STE C
-----------------------------------------------------
City | NEWPORT NEWS
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23606-4513
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-240-4180
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | VICKY POTTS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 757-240-4180
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320600000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
-----------------------------------------------------
License Number | 1214-08-011
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------