=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104819473
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY ADVOCACY RESOURCES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2005
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 124 SOUTH MAIN
-----------------------------------------------------
City | WOODWARD
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50276-0410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-438-4214
-----------------------------------------------------
Fax | 515-438-4217
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 410
-----------------------------------------------------
City | WOODWARD
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50276-0410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-438-4214
-----------------------------------------------------
Fax | 515-438-4217
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MR. CHARLES H WILKINSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 515-438-4214
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------