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General NPI Number Information
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NPI Number | 1154560050
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Entity Type | Organization
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Legal Business Name | SUSIE'S PLACE
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Dates
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Enumeration Date | 02/17/2009
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Last Update Date | 02/17/2009
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Provider Practice Location Address
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Address Line | 724 ASKEW ST
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City | BURLINGTON
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State | NC
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Zip | 27215-2202
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Country | US
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Telephone | 336-380-0772
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Fax | 336-270-6303
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Provider Business Mailing Address
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Address Line | PO BOX 5144
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City | BURLINGTON
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State | NC
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Zip | 27216-5144
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Country | US
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Telephone | 336-380-0772
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Fax | 336-270-6303
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Authorized Official
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Title or Position | MANAGER
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Name | MR. LORENZO MOORE
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Credential |
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Telephone | 336-380-0772
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 322D00000X
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Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
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License Number | 3747P1801X
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License Number State | NC
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