Healthcare Provider Details

I. General information

NPI: 1740470798
Provider Name (Legal Business Name): SUWS OF THE CAROLINAS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2007
Last Update Date: 07/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

363 GRAPHITE RD
OLD FORT NC
28762-9455
US

IV. Provider business mailing address

363 GRAPHITE RD
OLD FORT NC
28762-9455
US

V. Phone/Fax

Practice location:
  • Phone: 828-668-7590
  • Fax: 828-668-3162
Mailing address:
  • Phone: 828-668-7590
  • Fax: 828-668-3162

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License NumberMHL-059-032
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License NumberMHL-059-032
License Number StateNC

VIII. Authorized Official

Name: MISS KAREN NILSEN
Title or Position: ADMINISTRATIVE ASSISTANT
Credential:
Phone: 828-668-7590