=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336375682
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RJ SHEPHERD INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2009
-----------------------------------------------------
Last Update Date | 06/01/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1212 WALTER REED RD
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28304-4440
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-424-2929
-----------------------------------------------------
Fax | 910-424-2967
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1212 WALTER REED RD PO BOX 26702
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28304-4440
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-424-2929
-----------------------------------------------------
Fax | 910-424-2967
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MRS. TERESA RENEE OWENS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 910-424-2929
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------