Healthcare Provider Details

I. General information

NPI: 1164668414
Provider Name (Legal Business Name): STEPHENS OUTREACH CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2008
Last Update Date: 12/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2105B ELIZABETHTOWN ROAD
LUMBERTON NC
28358-3107
US

IV. Provider business mailing address

PO BOX 1462
FAIRMONT NC
28340-1110
US

V. Phone/Fax

Practice location:
  • Phone: 910-738-7865
  • Fax:
Mailing address:
  • Phone: 910-738-7865
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License NumberMHL078149
License Number StateNC

VIII. Authorized Official

Name: MR. MELVIN J STEPHENS
Title or Position: CEO
Credential:
Phone: 910-738-7865