MEDICARE: CISSELSALTERNATIVE

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	261QM0850X	Adult Mental Health Clinic/Center	MNL047109	NC

General Provider Information

NPI Number	:	1508039140
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CISSELSALTERNATIVE

Provider Business Mailing Address
First Line	:	126 DAVENPORT DR
Second Line	:
City	:	RAEFORD
State	:	NC
Zip	:	28376-5425
Country	:	US
Telephone Number	:	910-848-0216
Fax Number	:	910-848-0216

Provider Business Practice Location Address
First Line	:	126 DAVENPORT DR
Second Line	:
City	:	RAEFORD
State	:	NC
Zip	:	28376-5425
Country	:	US
Telephone Number	:	910-848-0216
Fax Number	:	910-848-0216

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. MARION WILSON CISSEL
Credential	:	12/07/46
Telephone Number	:	910-848-0216

Provider Enumeration Date	:	04/03/2008
Last Update Date	:	04/08/2008

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Directions to “CISSELSALTERNATIVE ” Practice Location

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