Healthcare Provider Details

I. General information

NPI: 1124182415
Provider Name (Legal Business Name): THE M CO. LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 07/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6576 CLIFFDALE RD
FAYETTEVILLE NC
28314-2047
US

IV. Provider business mailing address

3020 BROOKCROSSING DR VILLAGE AT LAKEWOOD
FAYETTEVILLE NC
28306-9790
US

V. Phone/Fax

Practice location:
  • Phone: 910-764-0954
  • Fax:
Mailing address:
  • Phone: 910-273-5838
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License NumberMHL026669
License Number StateNC

VIII. Authorized Official

Name: MRS. TERRY MIMS
Title or Position: OWNER
Credential:
Phone: 910-273-5838