=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508630476
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NC WELLNESS & RECOVERY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/13/2023
-----------------------------------------------------
Last Update Date | 01/03/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4006 PEACHTREE TOWN LN
-----------------------------------------------------
City | KNIGHTDALE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27545-7948
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-464-4283
-----------------------------------------------------
Fax | 919-420-3277
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4006 PEACHTREE TOWN LN
-----------------------------------------------------
City | KNIGHTDALE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27545-7948
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-464-4283
-----------------------------------------------------
Fax | 919-420-3277
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DAMEIN FORSYTHE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 919-464-4283
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------