1700174265 NPI number — ROBERSONVILLE PSYCHOSOCIAL REHABILITATION, LLC

Table of content: (NPI 1700174265)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700174265 NPI number — ROBERSONVILLE PSYCHOSOCIAL REHABILITATION, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROBERSONVILLE PSYCHOSOCIAL REHABILITATION, LLC
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:
1700174265
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/19/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
702 CROMWELL DR STE G
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27858-5436
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
252-745-5654
Provider Business Mailing Address Fax Number:
252-558-0655

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
110 E RAILROAD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROBERSONVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27871-0258
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-795-3311
Provider Business Practice Location Address Fax Number:
252-795-3303
Provider Enumeration Date:
07/19/2011

Additional Information

Authorized Official

Authorized Official Last Name:
SCHUTZ
Authorized Official First Name:
KATHY
Authorized Official Middle Name:
SHAW
Authorized Official Title or Position:
CEO/PRESIDENT
Authorized Official Telephone Number:
252-756-5654

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  MHL085047 , 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)





Copyright © 2007-2025 www.npivalidator.com