Healthcare Provider Details

I. General information

NPI: 1750517025
Provider Name (Legal Business Name): ENTERPRO STC SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2009
Last Update Date: 06/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1554 UNION RD STE B
GASTONIA NC
28054-5581
US

IV. Provider business mailing address

1554 UNION RD STE B
GASTONIA NC
28054-5581
US

V. Phone/Fax

Practice location:
  • Phone: 704-852-3053
  • Fax: 704-852-3756
Mailing address:
  • Phone: 704-852-3053
  • Fax: 704-852-3756

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberC001183
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License NumberC001183
License Number StateNC

VIII. Authorized Official

Name: MRS. SHANDA G KNOX
Title or Position: PRESIDENT
Credential: BS
Phone: 704-852-3053