Healthcare Provider Details

I. General information

NPI: 1396897161
Provider Name (Legal Business Name): PORT HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 05/24/2023
Certification Date: 05/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 HEALTH DRIVE
GREENVILLE NC
27834-7826
US

IV. Provider business mailing address

4300 SAPPHIRE CT STE 110
GREENVILLE NC
27834-9079
US

V. Phone/Fax

Practice location:
  • Phone: 252-413-1965
  • Fax: 252-413-0500
Mailing address:
  • Phone: 252-830-7540
  • Fax: 252-413-0932

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0401X
TaxonomyComprehensive Outpatient Rehabilitation Facility (CORF)
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License NumberMHL-074-111
License Number StateNC

VIII. Authorized Official

Name: BRETT BEAVERS
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 919-210-7661