Healthcare Provider Details

I. General information

NPI: 1639840341
Provider Name (Legal Business Name): ACHIEVEMENT CENTER ENRICHMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2021
Last Update Date: 09/28/2021
Certification Date: 09/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6605 E MARSHVILLE BLVD
MARSHVILLE NC
28103-1199
US

IV. Provider business mailing address

6605 E MARSHVILLE BLVD
MARSHVILLE NC
28103-1199
US

V. Phone/Fax

Practice location:
  • Phone: 336-587-2931
  • Fax:
Mailing address:
  • Phone: 336-587-2931
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RON FLACK JR.
Title or Position: OWNER
Credential: PHD
Phone: 336-587-2931