Healthcare Provider Details

I. General information

NPI: 1194179432
Provider Name (Legal Business Name): INDIVIDUALIZED TREATMENT SOLUTION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2016
Last Update Date: 04/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 HOLDEN BEACH RD SW
SHALLOTTE NC
28470-1787
US

IV. Provider business mailing address

1747 GRISSETT RD SW
SUPPLY NC
28462-3070
US

V. Phone/Fax

Practice location:
  • Phone: 910-393-9409
  • Fax:
Mailing address:
  • Phone: 910-393-9409
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code347B00000X
TaxonomyBus
License Number
License Number State

VIII. Authorized Official

Name: MS. SHARON WOODARD CRAWFORD
Title or Position: ADMINSTRATOR
Credential: A00002374
Phone: 910-393-9409