Provider Demographics
NPI:1043354061
Name:CUMBERLAND RESIDENTIAL & EMPLOYMENT SERVICES & TRAINING
Entity Type:Organization
Organization Name:CUMBERLAND RESIDENTIAL & EMPLOYMENT SERVICES & TRAINING
Other - Org Name:CREST
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DWAYNE
Authorized Official - Middle Name:K
Authorized Official - Last Name:PATTERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-487-3131
Mailing Address - Street 1:PO BOX 877
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28302-0877
Mailing Address - Country:US
Mailing Address - Phone:910-487-3131
Mailing Address - Fax:910-487-0637
Practice Address - Street 1:1533 MINTZ DRIVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303
Practice Address - Country:US
Practice Address - Phone:910-487-3131
Practice Address - Fax:910-487-0637
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-026-639320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7804522Medicaid