=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417725680
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAITH TO FATE COMMUNITY MINISTRIES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/18/2023
-----------------------------------------------------
Last Update Date | 12/18/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 720 MOOREFIELD PARK DR STE 100
-----------------------------------------------------
City | NORTH CHESTERFIELD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23236-3657
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-418-0876
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3586
-----------------------------------------------------
City | NORTH CHESTERFIELD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23235-7586
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-418-0876
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MR. IVAN TOLBERT
-----------------------------------------------------
Credential | MPA
-----------------------------------------------------
Telephone | 804-418-0876
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------