MEDICARE: CALM SOURCE 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	320800000X	Mental Illness Community Based Residential Treatment Facility	MHL-034-256	NC
2	251B00000X	Case Management Agency	7556	NC

General Provider Information

NPI Number	:	1447414636
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CALM SOURCE INC

Provider Business Mailing Address
First Line	:	895 PETERS CREEK PKWY STE 101
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27103-3858
Country	:	US
Telephone Number	:	336-970-7229
Fax Number	:

Provider Business Practice Location Address
First Line	:	149 GLENN BROOKE LN
Second Line	:
City	:	KING
State	:	NC
Zip	:	27021-9328
Country	:	US
Telephone Number	:	336-970-7229
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	ANTONIO D MCCLENDON
Credential	:
Telephone Number	:	336-970-7229

Provider Enumeration Date	:	07/16/2008
Last Update Date	:	05/20/2010

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Directions to “CALM SOURCE INC ” Practice Location

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