Healthcare Provider Details

I. General information

NPI: 1659692481
Provider Name (Legal Business Name): COMMUNITY SUPPORT PROFESSIONALS,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2010
Last Update Date: 06/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1606 WELLINGTON AVE UNIT C
WILMINGTON NC
28401-7704
US

IV. Provider business mailing address

1606 WELLINGTON AVE UNIT C
WILMINGTON NC
28401-7704
US

V. Phone/Fax

Practice location:
  • Phone: 910-799-4505
  • Fax: 910-799-4345
Mailing address:
  • Phone: 910-799-4505
  • Fax: 910-799-4345

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number8300728
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number8300728
License Number StateNC

VIII. Authorized Official

Name: MR. CHARLES CREECH
Title or Position: C.E.O
Credential:
Phone: 910-799-4505