Healthcare Provider Details

I. General information

NPI: 1902665771
Provider Name (Legal Business Name): BLACK EXCELLENCE STRIVING THERAPEUTIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2024
Last Update Date: 03/15/2024
Certification Date: 03/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

142 SOUTHERN PLAZA DR
DUDLEY NC
28333-9159
US

IV. Provider business mailing address

PO BOX 771
CLAYTON NC
27528-0771
US

V. Phone/Fax

Practice location:
  • Phone: 919-879-6090
  • Fax:
Mailing address:
  • Phone: 919-879-6090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. MARCUS DEONTOINE BEST
Title or Position: QUALIFIED PROFESSIONAL
Credential: MASTERS
Phone: 919-879-6090