=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124428016
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MUSTANG MEDICINE WORKS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/27/2014
-----------------------------------------------------
Last Update Date | 08/27/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5642 MOOREFIELD MEMORIAL HWY.
-----------------------------------------------------
City | LIBERTY
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29657
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-508-0781
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 702
-----------------------------------------------------
City | LIBERTY
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29657-0702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-508-0781
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | DR. DARRELL GENE YARDLEY
-----------------------------------------------------
Credential | PH.D., LPC
-----------------------------------------------------
Telephone | 864-508-0781
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 5933
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------