Healthcare Provider Details

I. General information

NPI: 1295377653
Provider Name (Legal Business Name): CAMPBELL SECOND CHANCE RECOVERY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2019
Last Update Date: 10/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 TARBORO ST
ROCKY MOUNT NC
27801-5955
US

IV. Provider business mailing address

115 APPOMATTOX DR
CAMERON NC
28326-5536
US

V. Phone/Fax

Practice location:
  • Phone: 910-556-6130
  • Fax:
Mailing address:
  • Phone: 910-556-6130
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State
# 11
Primary TaxonomyN
Taxonomy Code344600000X
TaxonomyTaxi
License Number
License Number State
# 12
Primary TaxonomyN
Taxonomy Code344800000X
TaxonomyAir Carrier
License Number
License Number State
# 13
Primary TaxonomyN
Taxonomy Code347B00000X
TaxonomyBus
License Number
License Number State
# 14
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State
# 15
Primary TaxonomyN
Taxonomy Code347D00000X
TaxonomyTrain
License Number
License Number State

VIII. Authorized Official

Name: MRS. CYNTHIA ANN CAMPBELL
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 910-556-6130