MEDICARE: FAMILY PREERVATION SERVICES, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency	158 02 029	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1164675948
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY PREERVATION SERVICES, INC

Provider Business Mailing Address
First Line	:	10304 SPOTSYLVANIA AVE
Second Line	:	3RD FLOOR
City	:	FREDERICKSBURG
State	:	VA
Zip	:	22408-8602
Country	:	US
Telephone Number	:	540-710-6085
Fax Number	:	540-710-6447

Provider Business Practice Location Address
First Line	:	2102 GRANDIN RD SW
Second Line	:
City	:	ROANOKE
State	:	VA
Zip	:	24015-3528
Country	:	US
Telephone Number	:	540-344-7048
Fax Number	:	540-344-7162

Authorized Official
Title or Position	:	CEO
Name	:	MR. MICHAEL C FIDGEON
Credential	:
Telephone Number	:	540-710-6085

Provider Enumeration Date	:	10/24/2008
Last Update Date	:	10/24/2008

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