1669663175 NPI number — ADDICTION RECOVERY MEDICAL SERVICES - PROVIDERS

Table of content: (NPI 1669663175)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669663175 NPI number — ADDICTION RECOVERY MEDICAL SERVICES - PROVIDERS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADDICTION RECOVERY MEDICAL SERVICES - PROVIDERS
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:
6
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:
1669663175
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/01/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1545
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STATESVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28687
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-880-4612
Provider Business Mailing Address Fax Number:
704-818-1115

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
536 SIGNAL HILL DR EXT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STATESVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28625
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-872-0234
Provider Business Practice Location Address Fax Number:
704-818-1115
Provider Enumeration Date:
08/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KEARNEY
Authorized Official First Name:
BOBBY
Authorized Official Middle Name:
PAXTON
Authorized Official Title or Position:
MD, MEDICAL DIRECTOR
Authorized Official Telephone Number:
704-880-5221

Provider Taxonomy Codes

  • Taxonomy code: 207LP2900X , with the licence number:  9300179 , 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)





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