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General NPI Number Information
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NPI Number | 1205996899
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Entity Type | Organization
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Legal Business Name | ABOVE AND BEYOND ENTERPRISE
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Dates
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Enumeration Date | 12/12/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 104 S CARPENTER ST
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City | KINGS MOUNTAIN
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State | NC
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Zip | 28086-3415
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Country | US
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Telephone | 704-734-1040
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Fax | 704-734-1095
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Provider Business Mailing Address
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Address Line | PO BOX 682
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City | KINGS MOUNTAIN
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State | NC
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Zip | 28086-0682
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Country | US
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Telephone | 704-734-1040
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Fax | 704-734-1095
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Authorized Official
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Title or Position | CEO
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Name | MR. LONNIE JAMES TUCKER JR.
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Credential |
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Telephone | 704-734-1040
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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 | MHL-023-108
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License Number State | NC
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Legacy Identifiers
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Identifier #1
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Identifier Code | 6603537
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Identifier Type | MEDICAID
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Identifier State | NC
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Identifier Issuer |
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Proprietary Identifiers Ever Reported
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Identifier #1
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Identifier Code | 6603537
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Identifier Type | MEDICAID
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Identifier State | NC
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Identifier Issuer |
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