Healthcare Provider Details

I. General information

NPI: 1104742790
Provider Name (Legal Business Name): SHIRLEY'S ENRICHMENT HOUSE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2026
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

169 TACKLE BOX DR
TROUTMAN NC
28166-0140
US

IV. Provider business mailing address

169 TACKLE BOX DR
TROUTMAN NC
28166-0140
US

V. Phone/Fax

Practice location:
  • Phone: 704-291-1454
  • Fax:
Mailing address:
  • Phone: 704-291-1454
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: CHRYSTAL GUINYARD
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 704-291-1454