Healthcare Provider Details

I. General information

NPI: 1346415809
Provider Name (Legal Business Name): CENTRAL CARE DIVISION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2008
Last Update Date: 09/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

907 WILLIAMS ST
EDEN NC
27288-5515
US

IV. Provider business mailing address

405 N. BRIDGE ST
EDEN NC
27288-5647
US

V. Phone/Fax

Practice location:
  • Phone: 336-635-2000
  • Fax: 336-635-2003
Mailing address:
  • Phone: 336-635-2000
  • Fax: 336-635-2003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License NumberMHL-079-088
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number StateNC

VIII. Authorized Official

Name: EDWARD F. STAPLES
Title or Position: OWNER
Credential:
Phone: 336-635-2000