Provider Demographics
NPI:1255825287
Name:KEDA,LLC
Entity Type:Organization
Organization Name:KEDA,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:
Authorized Official - Last Name:HARDCASTLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-725-8624
Mailing Address - Street 1:38 LITTLE ST
Mailing Address - Street 2:
Mailing Address - City:DUTTON
Mailing Address - State:VA
Mailing Address - Zip Code:23050-9732
Mailing Address - Country:US
Mailing Address - Phone:804-725-8624
Mailing Address - Fax:
Practice Address - Street 1:143 MAPLE RD
Practice Address - Street 2:
Practice Address - City:MATHEWS
Practice Address - State:VA
Practice Address - Zip Code:23109-2139
Practice Address - Country:US
Practice Address - Phone:804-725-8624
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-22
Last Update Date:2018-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA3205320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA3205OtherDBHDS LIC.#