MEDICARE: SELF-DETERMINATION LLC

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	261QD1600X	Developmental Disabilities Clinic/Center
2	320800000X	Mental Illness Community Based Residential Treatment Facility	023-197	NC
3	251S00000X	Community/Behavioral Health Agency
4	320800000X	Mental Illness Community Based Residential Treatment Facility
5	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility	012-129	NC
6	251B00000X	Case Management Agency

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

General Provider Information

NPI Number	:	1639408248
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SELF-DETERMINATION LLC

Provider Business Mailing Address
First Line	:	103 EBENEZER RD
Second Line	:
City	:	KINGS MTN
State	:	NC
Zip	:	28086-8762
Country	:	US
Telephone Number	:	704-750-4752
Fax Number	:	704-750-4753

Provider Business Practice Location Address
First Line	:	103 EBENEZER RD
Second Line	:
City	:	KINGS MTN
State	:	NC
Zip	:	28086
Country	:	US
Telephone Number	:	704-750-4752
Fax Number	:	704-750-4753

Authorized Official
Title or Position	:	PRESIDENT
Name	:	FLOYDCE JEFFERIES
Credential	:
Telephone Number	:	828-433-0465

Provider Enumeration Date	:	12/09/2009
Last Update Date	:	08/10/2018

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Directions to “SELF-DETERMINATION LLC ” Practice Location

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