Healthcare Provider Details

I. General information

NPI: 1124301676
Provider Name (Legal Business Name): SECOND NATURE BLUE RIDGE CAROLINA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2011
Last Update Date: 09/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 SWISS VILLAGE ROAD
OTTO NC
28763
US

IV. Provider business mailing address

PO BOX 809
CLAYTON GA
30525-0021
US

V. Phone/Fax

Practice location:
  • Phone: 706-212-2037
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License NumberMHL056024
License Number StateNC

VIII. Authorized Official

Name: DAN MCDOUGAL
Title or Position: PROGRAM DIRECTOR
Credential:
Phone: 706-212-2037