Healthcare Provider Details

I. General information

NPI: 1235676248
Provider Name (Legal Business Name): A BROADER FUTURE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2017
Last Update Date: 01/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3444 BRAGG BLVD
FAYETTEVILLE NC
28303-3946
US

IV. Provider business mailing address

882 SOUTHVIEW CIR
FAYETTEVILLE NC
28311-0318
US

V. Phone/Fax

Practice location:
  • Phone: 910-322-3001
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number2016-3437-01
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State

VIII. Authorized Official

Name: MS. ANDREA BROADNAX
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 910-286-7873