Provider Demographics
NPI:1568696904
Name:BROKEN CHAIN FOUNDATION
Entity Type:Organization
Organization Name:BROKEN CHAIN FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:CHRISTOPHER
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-405-3206
Mailing Address - Street 1:4824 KELLYWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-3643
Mailing Address - Country:US
Mailing Address - Phone:804-405-3206
Mailing Address - Fax:804-658-3105
Practice Address - Street 1:4824 KELLYWOOD DR
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23060-3643
Practice Address - Country:US
Practice Address - Phone:804-405-3206
Practice Address - Fax:804-658-3105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-13
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0000000000251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health