Provider Demographics
NPI:1093866691
Name:FAITH HOPE & CHARITY RESIDENTIAL CARE CENTER LLC
Entity Type:Organization
Organization Name:FAITH HOPE & CHARITY RESIDENTIAL CARE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:FAITH
Authorized Official - Middle Name:ANALISA
Authorized Official - Last Name:MOODY
Authorized Official - Suffix:
Authorized Official - Credentials:BACHELOR OF SOCIAL W
Authorized Official - Phone:757-692-2193
Mailing Address - Street 1:3409 DANA LANE
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452
Mailing Address - Country:US
Mailing Address - Phone:757-692-2193
Mailing Address - Fax:757-200-4535
Practice Address - Street 1:3409 DANA LANE
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452
Practice Address - Country:US
Practice Address - Phone:757-692-2193
Practice Address - Fax:757-200-4535
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA85301001320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010343780Medicaid
VA85301001OtherCOMMONWEALTH OF VA DMHMRS