Healthcare Provider Details

I. General information

NPI: 1033991906
Provider Name (Legal Business Name): PRIMARY HOPE OUTREACH CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2023
Last Update Date: 11/09/2023
Certification Date: 11/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1724 SETTER DR
BURLINGTON NC
27217-9444
US

IV. Provider business mailing address

1724 SETTER DR
BURLINGTON NC
27217-9444
US

V. Phone/Fax

Practice location:
  • Phone: 336-417-4164
  • Fax:
Mailing address:
  • Phone: 336-417-4164
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 11
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State
# 12
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State
# 13
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name: MRS. RASHAUNDA LAKEI PETTIFORD
Title or Position: OWNER
Credential:
Phone: 336-417-4164