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General NPI Number Information
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NPI Number | 1801413687
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Entity Type | Organization
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Legal Business Name | MILLENNIAL SERVICES OF NC AT ROCKINGHAM
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Dates
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Enumeration Date | 06/29/2020
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Last Update Date | 06/29/2020
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Provider Practice Location Address
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Address Line | 510 S TIPTON PL
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City | REIDSVILLE
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State | NC
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Zip | 27320-3039
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Country | US
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Telephone | 336-587-2931
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Fax |
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Provider Business Mailing Address
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Address Line | 1520 BOWMORE PL
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City | MC LEANSVILLE
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State | NC
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Zip | 27301-9248
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Country | US
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Telephone | 33-658-7293
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. RONALD FLACK JR.
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Credential | MA, PHD, ICADC, NCAC
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Telephone | 336-587-2931
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State |
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