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General NPI Number Information
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NPI Number | 1306224019
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Entity Type | Organization
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Legal Business Name | ADVANCE INTERGRATED MENTORING
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Dates
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Enumeration Date | 05/13/2015
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Last Update Date | 05/13/2015
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Provider Practice Location Address
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Address Line | 205 S SKIPPER ST
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City | ROCKINGHAM
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State | NC
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Zip | 28379-3843
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Country | US
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Telephone | 336-404-2110
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Fax |
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Provider Business Mailing Address
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Address Line | 205 S SKIPPER ST
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City | ROCKINGHAM
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State | NC
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Zip | 28379-3843
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Country | US
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Telephone | 336-404-2110
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Fax |
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Authorized Official
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Title or Position | THERAPIST
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Name | MR. SORDAO BERNARD MCKENZIE
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Credential | LCAS-A
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Telephone | 336-404-2110
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 252Y00000X
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Taxonomy Name | Early Intervention Provider Agency
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License Number | 2827-A
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License Number State | NC
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