=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194866608
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OUTREACH HOME # 4
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/08/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3007 DEARBORN DR
-----------------------------------------------------
City | DURHAM
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27704-2303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-220-0607
-----------------------------------------------------
Fax | 919-477-4700
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 305 SHALIMAR DR
-----------------------------------------------------
City | DURHAM
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27713-7571
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-641-0162
-----------------------------------------------------
Fax | 919-477-4700
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MRS. JOY N. OKEKE
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 919-201-8914
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number | MHL-032-394
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------