Healthcare Provider Details

I. General information

NPI: 1699082743
Provider Name (Legal Business Name): FIDELIS SUPPORT SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2010
Last Update Date: 09/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3905 FAUROT DR
COLUMBIA MO
65203-0309
US

IV. Provider business mailing address

3905 FAUROT DR
COLUMBIA MO
65203-0309
US

V. Phone/Fax

Practice location:
  • Phone: 573-424-4367
  • Fax:
Mailing address:
  • Phone: 573-424-4367
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. DOUGLAS L EDGAR
Title or Position: OWNER/QDDP
Credential:
Phone: 573-424-4367