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General NPI Number Information
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NPI Number | 1700051273
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Entity Type | Organization
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Legal Business Name | JOHN & JENNERINE ENTERPRISE, INC.
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Dates
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Enumeration Date | 04/25/2008
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Last Update Date | 02/04/2010
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Provider Practice Location Address
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Address Line | 116 PINEVIEW DR
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City | REIDSVILLE
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State | NC
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Zip | 27320-8126
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Country | US
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Telephone | 336-342-4033
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Fax | 336-852-6701
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Provider Business Mailing Address
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Address Line | PO BOX 1583
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City | REIDSVILLE
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State | NC
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Zip | 27323-1583
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Country | US
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Telephone | 336-342-4033
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Fax | 336-852-6701
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Authorized Official
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Title or Position | OWNER CEO
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Name | MRS. JENNERINE M. WALLACE
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Credential |
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Telephone | 336-852-6006
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 322D00000X
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Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
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License Number | MHL079092
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License Number State | NC
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