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General NPI Number Information
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NPI Number | 1013101781
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Entity Type | Organization
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Legal Business Name | BLACK RIVER HEALTH SERVICES, INC.
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Dates
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Enumeration Date | 09/05/2007
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 7910 US HIGHWAY 117 S SUITE 120
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City | ROCKY POINT
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State | NC
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Zip | 28457-7409
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Country | US
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Telephone | 910-675-0120
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Fax | 910-675-2308
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Provider Business Mailing Address
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Address Line | 301 S CAMPBELL ST
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City | BURGAW
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State | NC
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Zip | 28425-5011
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Country | US
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Telephone | 910-259-6973
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Fax | 910-259-6975
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | THOMAS SCOTT MARTIN
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Credential |
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Telephone | 910-259-6973
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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 |
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License Number State | NC
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