1962097626 NPI number — BREECHES BUOY ADDICTION MEDICINE SERVICES

Table of content: MRS. DEBORAH ANN WISE CNS (NPI 1134340599)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962097626 NPI number — BREECHES BUOY ADDICTION MEDICINE SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BREECHES BUOY ADDICTION MEDICINE SERVICES
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:
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Provider Other Credential Text:
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NPI Number Information

NPI Number:
1962097626
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/20/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3870
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLORENCE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29502-3870
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 W 27TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LUMBERTON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28358-3075
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-536-1689
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/04/2021

Additional Information

Authorized Official

Authorized Official Last Name:
HARDENBERGH
Authorized Official First Name:
MARLA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
208-578-6110

Provider Taxonomy Codes

  • Taxonomy code: 207RA0401X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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