Healthcare Provider Details

I. General information

NPI: 1548639594
Provider Name (Legal Business Name): EXECUTIVE ADDICTIONS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2015
Last Update Date: 09/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3451 GRAYSTONE PL SE
CONOVER NC
28613-8200
US

IV. Provider business mailing address

PO BOX 939
CONOVER NC
28613-0939
US

V. Phone/Fax

Practice location:
  • Phone: 828-261-0467
  • Fax: 828-465-6222
Mailing address:
  • Phone: 828-261-0467
  • Fax: 828-465-6222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: CATHLEEN C HANSEN
Title or Position: OWNER
Credential:
Phone: 828-261-0467