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General NPI Number Information
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NPI Number | 1124301676
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Entity Type | Organization
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Legal Business Name | SECOND NATURE BLUE RIDGE CAROLINA
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Dates
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Enumeration Date | 09/21/2011
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Last Update Date | 09/21/2011
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Provider Practice Location Address
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Address Line | 16 SWISS VILLAGE ROAD
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City | OTTO
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State | NC
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Zip | 28763
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Country | US
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Telephone | 706-212-2037
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 809
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City | CLAYTON
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State | GA
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Zip | 30525-0021
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PROGRAM DIRECTOR
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Name | DAN MCDOUGAL
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Credential |
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Telephone | 706-212-2037
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320800000X
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Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
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License Number | MHL056024
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License Number State | NC
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