MEDICARE: SAMARITANS NETWORK, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency		NC
2	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility	MHL-058-013	NC
3	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility	MHL-058-032	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1396981676
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAMARITANS NETWORK, INC

Provider Business Mailing Address
First Line	:	408 N MARTIN LUTHER KING JR DR
Second Line	:
City	:	WILLIAMSTON
State	:	NC
Zip	:	27892-1931
Country	:	US
Telephone Number	:	252-799-0300
Fax Number	:	252-799-0314

Provider Business Practice Location Address
First Line	:	408 N MARTIN LUTHER KING JR DR
Second Line	:	202 SOUTH HARRELL STREET
City	:	WILLIAMSTON
State	:	NC
Zip	:	27892-1931
Country	:	US
Telephone Number	:	252-799-0300
Fax Number	:	252-799-0314

Authorized Official
Title or Position	:	CEO
Name	:	MARIAN BROWN CANNON
Credential	:	BSW
Telephone Number	:	252-799-0300

Provider Enumeration Date	:	12/17/2008
Last Update Date	:	12/17/2008

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Practice Location Address:

408 N MARTIN LUTHER KING JR DR , 300 S. PEARL STREET
WILLIAMSTON, NC
27892-1931

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1003747122 — D'ASYA WILSON
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Practice Fax:

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Practice Location Address:

224 GREEN ST
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1619868635 — BWELL INTEGRATIVE PSYCHIATRY PLLC
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Directions to “SAMARITANS NETWORK, INC ” Practice Location

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