Healthcare Provider Details

I. General information

NPI: 1659813335
Provider Name (Legal Business Name): COMMUNITY OUTREACH YOUTH SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2016
Last Update Date: 07/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

177 CARDINAL AVE
LUMBERTON NC
28360-9386
US

IV. Provider business mailing address

177 CARDINAL AVE
LUMBERTON NC
28360-9386
US

V. Phone/Fax

Practice location:
  • Phone: 910-827-0111
  • Fax:
Mailing address:
  • Phone: 910-827-0111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License NumberMHL-078-317
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. ARLIS EMANUEL
Title or Position: CEO
Credential:
Phone: 910-827-0111