Provider Demographics
NPI:1215457254
Name:BLAKE HOME HEALTH AGENCY
Entity type:Organization
Organization Name:BLAKE HOME HEALTH AGENCY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIONNE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-545-1974
Mailing Address - Street 1:5709 S LABURNUM AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23231-4420
Mailing Address - Country:US
Mailing Address - Phone:804-545-1974
Mailing Address - Fax:888-314-9510
Practice Address - Street 1:11815 FOUNTAIN WAY STE 300
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-4448
Practice Address - Country:US
Practice Address - Phone:757-926-5241
Practice Address - Fax:888-314-9510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-21
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAHCO171615253Z00000X, 385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No385H00000XRespite Care FacilityRespite Care