1124518105 NPI number — FAMILY PRESERVATION SERVICES, INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124518105 NPI number — FAMILY PRESERVATION SERVICES, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY PRESERVATION SERVICES, 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's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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 Information

NPI Number:
1124518105
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/15/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10304 SPOTSYLVANIA AVE STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FREDERICKSBURG
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22408-8605
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-710-6085
Provider Business Mailing Address Fax Number:
540-710-6447

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3710 CHURCHVILLE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHURCHVILLE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24421-2500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
276-623-9245
Provider Business Practice Location Address Fax Number:
276-623-1183
Provider Enumeration Date:
05/15/2018

Additional Information

Authorized Official

Authorized Official Last Name:
QUARLES
Authorized Official First Name:
DONNA
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF CLINICAL RECORDS
Authorized Official Telephone Number:
540-993-1229

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  158-02-014 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 158-02-014 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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