Healthcare Provider Details

I. General information

NPI: 1144037078
Provider Name (Legal Business Name): DJ'S HOUSE CROP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2024
Last Update Date: 12/13/2024
Certification Date: 12/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7048 NC 210 HWY
SMITHFIELD NC
27577
US

IV. Provider business mailing address

7048 NC 210 HWY
SMITHFIELD NC
27577
US

V. Phone/Fax

Practice location:
  • Phone: 252-701-3177
  • Fax:
Mailing address:
  • Phone: 252-701-3177
  • Fax:

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 Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State

VIII. Authorized Official

Name: CORLISS C WILLIAMS
Title or Position: OWNER
Credential:
Phone: 252-820-2395