Healthcare Provider Details

I. General information

NPI: 1639219348
Provider Name (Legal Business Name): FULL POTENTIAL,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7238 PEBBLEBROOK DR
FAYETTEVILLE NC
28314-5232
US

IV. Provider business mailing address

PO BOX 25681
FAYETTEVILLE NC
28314-5011
US

V. Phone/Fax

Practice location:
  • Phone: 910-670-1989
  • Fax:
Mailing address:
  • Phone: 910-670-1989
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License NumberMHL026799
License Number StateNC

VIII. Authorized Official

Name: MR. JEROME S JOHNSON
Title or Position: CO-DIRECTOR
Credential: BA
Phone: 910-670-1989