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General NPI Number Information
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NPI Number | 1841612215
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Entity Type | Organization
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Legal Business Name | COLLEGE LAKES
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Dates
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Enumeration Date | 01/20/2014
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Last Update Date | 04/21/2021
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Provider Practice Location Address
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Address Line | 5104 FLATROCK DRIVE
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City | FAYETTEVILLE
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State | NC
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Zip | 28311
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Country | US
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Telephone | 910-488-6323
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Fax | 910-223-2180
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Provider Business Mailing Address
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Address Line | 5104 FLATROCK DRIVE
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City | FAYETTEVILLE
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State | NC
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Zip | 28311
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Country | US
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Telephone | 910-257-6406
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | NIKKI GIOVANNI CREECY
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Credential |
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Telephone | 910-257-6406
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320600000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
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License Number | MHL-047-133
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License Number State | NC
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