=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467534784
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UPLIFT COMPREHENSIVE SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/19/2006
-----------------------------------------------------
Last Update Date | 09/04/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 114 AVERY ST
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27858-1237
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-794-3834
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 31
-----------------------------------------------------
City | GARNER
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27529-0031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO/CO-OWNER
-----------------------------------------------------
Name | JOHN TAYLOR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 919-662-9918
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 322D00000X
-----------------------------------------------------
Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
-----------------------------------------------------
License Number | MHL-074-137
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------