Healthcare Provider Details

I. General information

NPI: 1356339154
Provider Name (Legal Business Name): BLACK RIVER HEALTH SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2005
Last Update Date: 01/21/2020
Certification Date: 01/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4811 NC HIGHWAY 50
MAPLE HILL NC
28454-8153
US

IV. Provider business mailing address

301 S CAMPBELL ST
BURGAW NC
28425-5011
US

V. Phone/Fax

Practice location:
  • Phone: 910-259-6444
  • Fax: 910-259-6659
Mailing address:
  • Phone: 910-259-6973
  • Fax: 910-259-6975

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LEEANN AMANN
Title or Position: ADMINISTRATOR
Credential:
Phone: 910-259-6973