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NPI Code Detail

MEDICARE: EDGEWOOD GROUP FAMILY SERVICES

MEDICARE: EDGEWOOD GROUP FAMILY SERVICES
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1251S00000XCommunity/Behavioral Health Agency709VA

General Provider Information

NPI Number : 1396043212
Entity Type Code : Organization
Provider Name (Legal Business Name) : EDGEWOOD GROUP FAMILY SERVICES
Provider Business Mailing Address
First Line : 4906 FITZHUGH AVE STE 104
Second Line :
City : RICHMOND
State : VA
Zip : 23230-3520
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 4906 FITZHUGH AVE STE 104
Second Line :
City : RICHMOND
State : VA
Zip : 23230-3520
Country : US
Telephone Number : 804-648-0671
Fax Number :
Authorized Official
Title or Position : DOS
Name : MR. TRAVIS CROCKER
Credential :
Telephone Number : 804-648-0671
Provider Enumeration Date : 03/01/2011
Last Update Date : 03/01/2011

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