=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003228214
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FJV FOUNDATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2014
-----------------------------------------------------
Last Update Date | 05/21/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1601 OSPREY DR SUITE 206
-----------------------------------------------------
City | DESOTO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75115-8818
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-786-3475
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1601 OSPREY DR SUITE 206
-----------------------------------------------------
City | DESOTO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75115-8818
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MRS. TONIA GRANGER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 972-786-3475
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332U00000X
-----------------------------------------------------
Taxonomy Name | Home Delivered Meals
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------