1174558266 NPI number — FAIRFAX COUNTY, VIRGINIA

Table of content: (NPI 1174558266)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174558266 NPI number — FAIRFAX COUNTY, VIRGINIA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAIRFAX COUNTY, VIRGINIA
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:
FAIRFAX FALLS CHURCH COMMUNITY SERVICES BOARD - DD SERVICES
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 Information

NPI Number:
1174558266
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/01/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12000 GOVERNMENT CENTER PKWY
Provider Second Line Business Mailing Address:
SUITE 552
Provider Business Mailing Address City Name:
FAIRFAX
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22035-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-324-3360
Provider Business Mailing Address Fax Number:
703-324-4573

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12011 GOVERNMENT CENTER PKWY
Provider Second Line Business Practice Location Address:
SUITE 836
Provider Business Practice Location Address City Name:
FAIRFAX
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22035-1100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-324-7000
Provider Business Practice Location Address Fax Number:
703-324-7092
Provider Enumeration Date:
07/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WASHINGTON
Authorized Official First Name:
DARYL
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
703-324-7000

Provider Taxonomy Codes

  • Taxonomy code: 261QM1300X , with the licence number:  113 , 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: 004945620 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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