Provider Demographics
NPI:1699082743
Name:FIDELIS SUPPORT SERVICES LLC
Entity type:Organization
Organization Name:FIDELIS SUPPORT SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/QDDP
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:L
Authorized Official - Last Name:EDGAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-424-4367
Mailing Address - Street 1:3905 FAUROT DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-0309
Mailing Address - Country:US
Mailing Address - Phone:573-424-4367
Mailing Address - Fax:
Practice Address - Street 1:3905 FAUROT DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-0309
Practice Address - Country:US
Practice Address - Phone:573-424-4367
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-10
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities