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General NPI Number Information
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NPI Number | 1225428634
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Entity Type | Organization
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Legal Business Name | FOKUS RESIDENTIAL SERVICES, LLC
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Dates
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Enumeration Date | 01/23/2015
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Last Update Date | 01/23/2015
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Provider Practice Location Address
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Address Line | 411 TILLMAN ST
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City | BURLINGTON
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State | NC
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Zip | 27217-2358
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Country | US
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Telephone | 336-350-8420
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Fax |
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Provider Business Mailing Address
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Address Line | 3116 JUNIPER DR
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City | BURLINGTON
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State | NC
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Zip | 27215-7934
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Country | US
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Telephone | 336-270-6004
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | MR. KEITH DERRICK HAITH
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Credential | BS
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Telephone | 336-675-4713
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320800000X
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Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
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License Number | 001-235
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License Number State | NC
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