=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043350127
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY PRESERVATIONS SERVICES, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2007
-----------------------------------------------------
Last Update Date | 08/12/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | RR 1 BOX 552
-----------------------------------------------------
City | JONESVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24263-9505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-431-7214
-----------------------------------------------------
Fax | 276-431-7215
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10304 SPOTSYLVANIA AVE SUITE 300
-----------------------------------------------------
City | FREDERICKSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22408-8602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-710-6085
-----------------------------------------------------
Fax | 540-710-6419
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MICHAEL FIDGEON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 540-710-6085
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 15802029
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------