Healthcare Provider Details

I. General information

NPI: 1841635455
Provider Name (Legal Business Name): MCPC-11, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2013
Last Update Date: 02/05/2025
Certification Date: 02/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42 MEMORIAL DR
PINEHURST NC
28374-8707
US

IV. Provider business mailing address

42 MEMORIAL DR
PINEHURST NC
28374-8707
US

V. Phone/Fax

Practice location:
  • Phone: 910-715-3376
  • Fax: 910-715-5391
Mailing address:
  • Phone: 910-715-3376
  • Fax: 910-715-5391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MICKEY FOSTER
Title or Position: CEO
Credential:
Phone: 910-715-1443