Healthcare Provider Details

I. General information

NPI: 1952539850
Provider Name (Legal Business Name): BROTHERS COMMUNITY RESOURCES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2009
Last Update Date: 06/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 W CHURCH ST STE B
CREEDMOOR NC
27522-9765
US

IV. Provider business mailing address

2556 MINT JULEP DR
CREEDMOOR NC
27522-7817
US

V. Phone/Fax

Practice location:
  • Phone: 919-528-4900
  • Fax: 919-528-1234
Mailing address:
  • Phone: 919-528-4900
  • Fax: 919-528-1234

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: CLARENCE MARCELLUS
Title or Position: OWNER
Credential:
Phone: 919-528-4900