=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154162667
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FIDELIS ADULT HOME CARE SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2024
-----------------------------------------------------
Last Update Date | 06/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2320 W ROCKWELL AVE
-----------------------------------------------------
City | SPOKANE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99205-1470
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-638-9401
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6805 N BELT ST
-----------------------------------------------------
City | SPOKANE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99208-4301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-638-9401
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | NATHANIEL M BALLANTYNE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 509-850-7442
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------