=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326324641
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DAYMARK RECOVERY SERVICES INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2011
-----------------------------------------------------
Last Update Date | 09/14/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 940 W LEBANON ST
-----------------------------------------------------
City | MOUNT AIRY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27030-2222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-679-8805
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 284 EXECUTIVE PARK DR SUITE 100
-----------------------------------------------------
City | CONCORD
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28025-1894
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MR. BILLY R WEST JR.
-----------------------------------------------------
Credential | M.S.W.,L.C.S.W.
-----------------------------------------------------
Telephone | 704-939-1100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------