Provider Demographics
NPI:1033252440
Name:STEPHENS OUTREACH CENTER, INC
Entity Type:Organization
Organization Name:STEPHENS OUTREACH CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MELVIN
Authorized Official - Middle Name:JUNIOR
Authorized Official - Last Name:STEPHENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-308-4847
Mailing Address - Street 1:PO BOX 1462
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:NC
Mailing Address - Zip Code:28340-1123
Mailing Address - Country:US
Mailing Address - Phone:910-308-4847
Mailing Address - Fax:910-738-7876
Practice Address - Street 1:608A MARTIN LUTHER KING DR
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:NC
Practice Address - Zip Code:28340-1312
Practice Address - Country:US
Practice Address - Phone:910-308-4847
Practice Address - Fax:910-738-7876
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL078149320600000X, 322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8301487Medicaid