=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225318587
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SWIM NETWORK, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2011
-----------------------------------------------------
Last Update Date | 08/18/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 403 ATLANTIC AVE
-----------------------------------------------------
City | ROCKY MOUNT
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27801-5313
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-972-7946
-----------------------------------------------------
Fax | 252-972-7946
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1314
-----------------------------------------------------
City | ROCKY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-972-7946
-----------------------------------------------------
Fax | 252-972-7946
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MS. TILDA DENORA WHITAKER
-----------------------------------------------------
Credential | QSAP
-----------------------------------------------------
Telephone | 252-972-7946
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number | MHL-033-103
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------