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General NPI Number Information
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NPI Number | 1184748238
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Entity Type | Organization
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Legal Business Name | MYBROTHERSKEEPER
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Dates
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Enumeration Date | 03/16/2007
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Last Update Date | 07/31/2008
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Provider Practice Location Address
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Address Line | 816 PAUL ST
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City | ROCKY MOUNT
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State | NC
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Zip | 27803-3337
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Country | US
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Telephone | 252-985-2735
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Fax | 252-985-1952
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Provider Business Mailing Address
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Address Line | 816 PAUL ST
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City | ROCKY MOUNT
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State | NC
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Zip | 27803-3337
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Country | US
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Telephone | 252-985-2735
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Fax | 252-985-1952
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MS. BARBARA JEAN WILSON
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Credential | OWNER
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Telephone | 252-985-2735
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number | MHL064060
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License Number State | NC
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