Healthcare Provider Details

I. General information

NPI: 1699080770
Provider Name (Legal Business Name): BRITESMILZ FAMILY & COMMUNITY CONNECTIONS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2010
Last Update Date: 08/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1165 GREGORY DR
ROANOKE RAPIDS NC
27870-6442
US

IV. Provider business mailing address

1165 GREGORY DR
ROANOKE RAPIDS NC
27870-6442
US

V. Phone/Fax

Practice location:
  • Phone: 252-537-7575
  • Fax: 252-537-9008
Mailing address:
  • Phone: 252-537-7575
  • Fax: 252-537-9008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. EVELYN S. DAWSON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 252-537-7575