Healthcare Provider Details

I. General information

NPI: 1447414636
Provider Name (Legal Business Name): CALM SOURCE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2008
Last Update Date: 05/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

149 GLENN BROOKE LN
KING NC
27021-9328
US

IV. Provider business mailing address

895 PETERS CREEK PKWY STE 101
WINSTON SALEM NC
27103-3858
US

V. Phone/Fax

Practice location:
  • Phone: 336-970-7229
  • Fax:
Mailing address:
  • Phone: 336-970-7229
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number7556
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License NumberMHL-034-256
License Number StateNC

VIII. Authorized Official

Name: ANTONIO D MCCLENDON
Title or Position: PRESIDENT/CEO
Credential:
Phone: 336-970-7229