Healthcare Provider Details

I. General information

NPI: 1306914106
Provider Name (Legal Business Name): FLYNN FELLOWSHIP HOME OF GASTONIA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 03/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 S MARIETTA ST
GASTONIA NC
28052-4365
US

IV. Provider business mailing address

311 S MARIETTA ST
GASTONIA NC
28052-4365
US

V. Phone/Fax

Practice location:
  • Phone: 704-865-9395
  • Fax: 704-862-0399
Mailing address:
  • Phone: 704-865-9395
  • Fax: 704-862-0399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License NumberMHL-036-007
License Number StateNC

VIII. Authorized Official

Name: MRS. LINDA M. MARTIN
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 704-865-9395