1063528560 NPI number — FAMILY PRESERVATION SERVICES OF FLORIDA, INC.

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063528560 NPI number — FAMILY PRESERVATION SERVICES OF FLORIDA, INC.

Employer Identification Number (EIN):

Provider Organization Name:

FAMILY PRESERVATION SERVICES OF FLORIDA, INC.

Provider Last Name:

Provider First Name:

Provider Middle Name:

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

Provider Gender Code:

Provider Other Organization Name:

PATHWAYS HUMAN SERVICES OF FLORIDA

Provider Other Organization Name Type Code:

3

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number:

1063528560

Entity Type Code:

Organization

Replacement NPI:

Last Update Date:

05/10/2017

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

121 N 2ND STREET

Provider Second Line Business Mailing Address:

SUITE 301

Provider Business Mailing Address City Name:

FORT PIERCE

Provider Business Mailing Address State Name:

FL

Provider Business Mailing Address Postal Code:

34950-4435

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

772-595-3773

Provider Business Mailing Address Fax Number:

772-293-0076

Provider First Line Business Practice Location Address:

121 N 2ND ST STE 301

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

FORT PIERCE

Provider Business Practice Location Address State Name:

FL

Provider Business Practice Location Address Postal Code:

34950-4435

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

772-595-3773

Provider Business Practice Location Address Fax Number:

772-293-0076

Provider Enumeration Date:

08/21/2006

Authorized Official Last Name:

FIDGEON

Authorized Official First Name:

MICHAEL

Authorized Official Middle Name:

C

Authorized Official Title or Position:

PRESIDENT

Authorized Official Telephone Number:

540-710-2823

• Taxonomy code: 251B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 251K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 070609403 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
• Identifier: 760557900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
• Identifier: 760557902 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
• Identifier: 766141000 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
• Identifier: 001567600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
• Identifier: 070892501 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
• Identifier: 001568900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
• Identifier: 070863100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
• Identifier: 001568800 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
• Identifier: 070604300 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
• Identifier: 070609400 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
• Identifier: 070863103 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".