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General NPI Number Information
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NPI Number | 1902999568
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Entity Type | Organization
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Legal Business Name | PENTECOSTAL TEMPLE RESIDENTIAL SERVICES, INC.
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Dates
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Enumeration Date | 10/02/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 2753 W 5TH ST
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City | GREENVILLE
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State | NC
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Zip | 27834-7817
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Country | US
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Telephone | 252-752-0057
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Fax | 252-830-4094
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Provider Business Mailing Address
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Address Line | PO BOX 983
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City | GREENVILLE
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State | NC
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Zip | 27835-0983
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Country | US
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Telephone | 252-752-0057
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Fax | 252-830-4094
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Authorized Official
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Title or Position | CLINICAL DIRECTOR
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Name | MRS. CHRISTINA SIMS-SMITH
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Credential | BS, QP
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Telephone | 252-752-6951
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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 | MHL-115
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License Number State | NC
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