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General NPI Number Information
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NPI Number | 1083070718
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Entity Type | Organization
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Legal Business Name | ROOSEVELT'S CHARACTER DEVELOPMENT CENTER
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Dates
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Enumeration Date | 01/11/2016
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Last Update Date | 01/11/2016
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Provider Practice Location Address
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Address Line | 119 S COLLEGE ST
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City | STATESBORO
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State | GA
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Zip | 30458-5202
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Country | US
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Telephone | 912-541-2809
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Fax |
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Provider Business Mailing Address
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Address Line | 119 S COLLEGE ST
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City | STATESBORO
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State | GA
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Zip | 30458-5202
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Country | US
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Telephone | 912-541-2809
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MR. ROOSEVELT CONE JR.
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Credential |
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Telephone | 912-541-2809
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TB0200X
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Taxonomy Name | Cognitive & Behavioral Psychologist
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License Number |
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License Number State |
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