1982818399 NPI number — SOUL SHINE CHILDREN'S TREATMENT SERVICES, INC.

Table of content: (NPI 1982818399)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982818399 NPI number — SOUL SHINE CHILDREN'S TREATMENT SERVICES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUL SHINE CHILDREN'S TREATMENT SERVICES, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1982818399
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/09/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1546
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEMBROKE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28372-1546
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-536-6094
Provider Business Mailing Address Fax Number:
910-843-9728

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
218 E 2ND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RED SPRINGS
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28377-1308
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-536-6094
Provider Business Practice Location Address Fax Number:
910-843-9728
Provider Enumeration Date:
05/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DEESE
Authorized Official First Name:
LESHIA
Authorized Official Middle Name:
ROGERS
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
910-536-6094

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  LCAS-21969 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: C005175 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 6106174 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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