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General NPI Number Information
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NPI Number | 1215114715
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Entity Type | Organization
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Legal Business Name | SUCCESS DYNAMICS COMMUNITY DEVELOPMENT CORPORATION
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Dates
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Enumeration Date | 01/28/2008
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Last Update Date | 07/22/2008
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Provider Practice Location Address
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Address Line | 7227 STATONSBURG ROAD
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City | FARMVILLE
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State | NC
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Zip | 27828-0214
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Country | US
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Telephone | 252-753-7815
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Fax | 252-753-8787
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Provider Business Mailing Address
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Address Line | PO BOX 214
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City | FARMVILLE
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State | NC
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Zip | 27828-0214
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Country | US
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Telephone | 252-753-7815
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Fax | 252-753-8787
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | DR. CALVIN O. ELLISON
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Credential | N.D., PHD
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Telephone | 252-753-7815
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number |
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License Number State | NC
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