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General NPI Number Information
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NPI Number | 1285027839
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Entity Type | Organization
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Legal Business Name | A LEGACY FAFILLED
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Dates
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Enumeration Date | 03/06/2015
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Last Update Date | 03/06/2015
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Provider Practice Location Address
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Address Line | 3712 MIZELL RD APT F
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City | GREENSBORO
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State | NC
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Zip | 27405-4717
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Country | US
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Telephone | 336-383-7414
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Fax |
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Provider Business Mailing Address
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Address Line | 3712 MIZELL RD APT F
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City | GREENSBORO
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State | NC
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Zip | 27405-4717
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | RAYMOND HORNE
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Credential |
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Telephone | 336-383-7414
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State |
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