Healthcare Provider Details

I. General information

NPI: 1275027294
Provider Name (Legal Business Name): TONYA CLARK FREEMAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2018
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 W RIVER ST
COLERAIN NC
27924-8879
US

IV. Provider business mailing address

404 W RIVER ST
COLERAIN NC
27924-8879
US

V. Phone/Fax

Practice location:
  • Phone: 252-356-9954
  • Fax:
Mailing address:
  • Phone: 252-356-9954
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberFCL008043
License Number StateNC

VIII. Authorized Official

Name: TONYA C FREEMAN
Title or Position: OWNER/ADMINISTRATOR
Credential:
Phone: 252-642-2665