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General NPI Number Information
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NPI Number | 1811058803
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Entity Type | Organization
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Legal Business Name | RANDOLPH JUVENILE DAY REPORTING CENTER
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Dates
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Enumeration Date | 12/13/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1520 N FAYETTEVILLE ST
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City | ASHEBORO
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State | NC
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Zip | 27203-3894
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Country | US
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Telephone | 336-683-8228
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Fax | 336-683-8217
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Provider Business Mailing Address
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Address Line | 1520 N FAYETTEVILLE ST
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City | ASHEBORO
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State | NC
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Zip | 27203-3894
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Country | US
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Telephone | 336-683-8228
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Fax | 336-683-8217
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Authorized Official
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Title or Position | MANAGER
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Name | MR. JOHN THURMAN MORRISSETT
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Credential | LPC
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Telephone | 336-683-8228
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | MHL-076-030
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License Number State | NC
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