=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467006353
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HOUSE OF JEWELS, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2019
-----------------------------------------------------
Last Update Date | 07/29/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 107 ROBINSON DR
-----------------------------------------------------
City | CHERRYVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28021-8100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-214-1174
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 BLACK ELK LN
-----------------------------------------------------
City | BLYTHEWOOD
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29016-7220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF OPERATIONS
-----------------------------------------------------
Name | GENITA DOUGLAS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 704-214-1174
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3245S0500X
-----------------------------------------------------
Taxonomy Name | Children's Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 320800000X
-----------------------------------------------------
Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------