MEDICARE: INFLUENTIAL FAMILY SERVICE, 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	251E00000X	Home Health Agency	1346-05-001	VA
2	251S00000X	Community/Behavioral Health Agency	1346-05-001	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	:	1912235235
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INFLUENTIAL FAMILY SERVICE, INC.

Provider Business Mailing Address
First Line	:	3122 W. MARSHALL ST
Second Line	:	10
City	:	RICHMOND
State	:	VA
Zip	:	23230
Country	:	US
Telephone Number	:	804-355-1853
Fax Number	:

Provider Business Practice Location Address
First Line	:	3122 W. MARSHALL ST
Second Line	:	10
City	:	RICHMOND
State	:	VA
Zip	:	23230-4726
Country	:	US
Telephone Number	:	804-355-1853
Fax Number	:

Authorized Official
Title or Position	:	COO
Name	:	MR. DERRICK CHAVIS
Credential	:
Telephone Number	:	804-355-1853

Provider Enumeration Date	:	11/24/2009
Last Update Date	:	11/24/2009

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