MEDICARE: FOUNDATIONS SUPPORTIVE CARE, LLC

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	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1376390831
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOUNDATIONS SUPPORTIVE CARE, LLC

Provider Business Mailing Address
First Line	:	2412 HARPOON DR
Second Line	:
City	:	STAFFORD
State	:	VA
Zip	:	22554-2521
Country	:	US
Telephone Number	:	571-355-5805
Fax Number	:

Provider Business Practice Location Address
First Line	:	3501 CASTLE HILL DR
Second Line	:
City	:	WOODBRIDGE
State	:	VA
Zip	:	22193-5326
Country	:	US
Telephone Number	:	571-355-5805
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MRS. DONALDA JONES
Credential	:
Telephone Number	:	571-355-5805

Provider Enumeration Date	:	05/02/2024
Last Update Date	:	05/02/2024

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