Healthcare Provider Details

I. General information

NPI: 1942333240
Provider Name (Legal Business Name): SPIRIT OF EXCELLENCE COMMUNITY OUTREACH,INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 02/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 HENDERSON DR
JACKSONVILLE NC
28540-5601
US

IV. Provider business mailing address

PO BOX 752
JACKSONVILLE NC
28541-0752
US

V. Phone/Fax

Practice location:
  • Phone: 910-939-4663
  • Fax: 910-939-5079
Mailing address:
  • Phone: 910-939-4663
  • Fax: 910-939-5079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License NumberMHL-067-164
License Number StateNC
# 8
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State
# 9
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. HELEN DELORISE FLUDD
Title or Position: CEO
Credential:
Phone: 910-382-6595