=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538823737
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SACRED HEALTH INCORPORATED
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/25/2021
-----------------------------------------------------
Last Update Date | 10/25/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3416 VIRGINIA AVE STE 3
-----------------------------------------------------
City | COLLINSVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24078-2240
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-403-0258
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1071 MATCHSTICK PL SW
-----------------------------------------------------
City | CONCORD
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28025-4706
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-604-2090
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. WILLIAM BERNARD GAUSE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 704-604-2090
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------