Provider Demographics
NPI:1871463661
Name:PEDEREC SUPPORTED LIVING LLC
Entity type:Organization
Organization Name:PEDEREC SUPPORTED LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JEROLINE
Authorized Official - Middle Name:
Authorized Official - Last Name:FAI
Authorized Official - Suffix:
Authorized Official - Credentials:BSN
Authorized Official - Phone:571-327-7252
Mailing Address - Street 1:14115 LOVERS LN STE 120
Mailing Address - Street 2:
Mailing Address - City:CULPEPER
Mailing Address - State:VA
Mailing Address - Zip Code:22701-4157
Mailing Address - Country:US
Mailing Address - Phone:571-237-7725
Mailing Address - Fax:757-935-0240
Practice Address - Street 1:14115 LOVERS LN STE 120
Practice Address - Street 2:
Practice Address - City:CULPEPER
Practice Address - State:VA
Practice Address - Zip Code:22701-4157
Practice Address - Country:US
Practice Address - Phone:571-237-7725
Practice Address - Fax:757-935-0240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-11-07
Last Update Date:2025-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No253Z00000XAgenciesIn Home Supportive Care