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General NPI Number Information
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NPI Number | 1003145665
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Entity Type | Organization
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Legal Business Name | SAM/OUTREACH PROGRAM
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Dates
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Enumeration Date | 12/10/2009
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Last Update Date | 12/10/2009
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Provider Practice Location Address
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Address Line | 114 E MAIN ST STE. B
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City | LINCOLNTON
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State | NC
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Zip | 28092-2725
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Country | US
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Telephone | 704-740-6512
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Fax | 704-735-4995
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Provider Business Mailing Address
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Address Line | PO BOX 1710
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City | LINCOLNTON
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State | NC
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Zip | 28093-1710
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Country | US
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Telephone | 704-740-6512
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Fax | 704-735-4995
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MRS. ROSALIND TERRELLE BYNUM
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Credential |
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Telephone | 704-740-6512
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | MHL-055-114
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License Number State | NC
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