Healthcare Provider Details

I. General information

NPI: 1356553630
Provider Name (Legal Business Name): BOYS TO GENTLEMEN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 CLAYTON RD
DURHAM NC
27703-3508
US

IV. Provider business mailing address

202 CLAYTON RD
DURHAM NC
27703-3508
US

V. Phone/Fax

Practice location:
  • Phone: 919-598-5355
  • Fax:
Mailing address:
  • Phone: 919-598-5355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier8301594
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

Name: MS. LORRAIN W MEADOWS
Title or Position: OWNER
Credential:
Phone: 919-598-5355