Healthcare Provider Details

I. General information

NPI: 1194379016
Provider Name (Legal Business Name): SPENCER HINTON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2019
Last Update Date: 07/15/2022
Certification Date: 07/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2728 S. RIDGE AVE.
CONCORD NC
28025
US

IV. Provider business mailing address

2728 S. RIDGE AVE.
CONCORD NC
28025
US

V. Phone/Fax

Practice location:
  • Phone: 252-205-7344
  • Fax:
Mailing address:
  • Phone: 252-205-7344
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: