Healthcare Provider Details

I. General information

NPI: 1992947154
Provider Name (Legal Business Name): SOMMERVILLE GROUP SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2009
Last Update Date: 04/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1017 WOODKIRK LN
MATTHEWS NC
28104-8053
US

IV. Provider business mailing address

1017 WOODKIRK LN
MATTHEWS NC
28104-8053
US

V. Phone/Fax

Practice location:
  • Phone: 704-219-6084
  • Fax:
Mailing address:
  • Phone: 704-219-6084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number168913
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number168913
License Number StateNC

VIII. Authorized Official

Name: KENNETH ASAH FON-NDIKUM
Title or Position: CO-FOUNDER
Credential:
Phone: 704-219-6084