=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346526886
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DAYMARK RECOVERY SERVICES INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/28/2011
-----------------------------------------------------
Last Update Date | 09/11/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1400 WILLOW LN
-----------------------------------------------------
City | N WILKESBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28659-3551
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-667-5151
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 284 EXECUTIVE PARK DR SUITE 100
-----------------------------------------------------
City | CONCORD
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28025-1894
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-939-1100
-----------------------------------------------------
Fax | 704-939-1173
-----------------------------------------------------
=====================================================
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 | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------