=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093903874
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMMUNITY HEALTHWATCH SERVICES INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2007
-----------------------------------------------------
Last Update Date | 10/05/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 280 PINEHURST AVE STE A
-----------------------------------------------------
City | SOUTHERN PINES
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28387-6350
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-695-4250
-----------------------------------------------------
Fax | 910-695-4251
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 280 PINEHURST AVE STE A
-----------------------------------------------------
City | SOUTHERN PINES
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28387-6350
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-695-4250
-----------------------------------------------------
Fax | 910-695-4251
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | HUMAN RESOURCE MANAGER
-----------------------------------------------------
Name | NELSON JACKSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 910-695-4250
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------