Provider Demographics
NPI:1093226110
Name:PROMISES12 LTD LLC
Entity Type:Organization
Organization Name:PROMISES12 LTD LLC
Other - Org Name:ASSESSMENTS@PROMISES12
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:ERIC
Authorized Official - Last Name:INGRAM
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, CSAC
Authorized Official - Phone:704-786-1500
Mailing Address - Street 1:3018 ROSEHILL DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28212-5721
Mailing Address - Country:US
Mailing Address - Phone:704-786-1500
Mailing Address - Fax:704-786-1501
Practice Address - Street 1:35 MEANS AVE SE
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-3563
Practice Address - Country:US
Practice Address - Phone:704-786-1500
Practice Address - Fax:704-786-1501
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROMISES12 LTD LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-10-16
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1146654261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder