Healthcare Provider Details

I. General information

NPI: 1639232044
Provider Name (Legal Business Name): CLUB NOVA COMMUNITY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 09/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 W MAIN ST SUITE D
CARRBORO NC
27510-2072
US

IV. Provider business mailing address

103 W MAIN ST SUITE D
CARRBORO NC
27510-2072
US

V. Phone/Fax

Practice location:
  • Phone: 919-968-6682
  • Fax: 919-968-1764
Mailing address:
  • Phone: 919-968-6682
  • Fax: 919-968-1764

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberMHL068017
License Number StateNC

VIII. Authorized Official

Name: JACOB LONG
Title or Position: ASSOCIATE DIRECTOR OF ADMINISTRATIO
Credential:
Phone: 919-968-6682