=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285983528
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALTERNATIVE COMMUNITY PENALTIES PROGRAM, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2012
-----------------------------------------------------
Last Update Date | 06/28/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 EAST FIFTH AVENUE
-----------------------------------------------------
City | GASTONIA
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28054
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-867-8749
-----------------------------------------------------
Fax | 704-869-8892
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P.O. BOX 370
-----------------------------------------------------
City | GASTONIA
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28053-0370
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-671-1030
-----------------------------------------------------
Fax | 704-869-7336
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MR. LAWRENCE DOUGLAS LANCE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 704-867-8749
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320800000X
-----------------------------------------------------
Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
-----------------------------------------------------
License Number | MHL-0360297
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------