Provider Demographics
NPI:1467591412
Name:A MOTHER'S LOVE ENRICHMENT AGENCY EXTENDED
Entity Type:Organization
Organization Name:A MOTHER'S LOVE ENRICHMENT AGENCY EXTENDED
Other - Org Name:A MOTHER'S LOVE ENRICHMENT AGENCY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER AGENCY CONTROLS DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:QUEESHA
Authorized Official - Middle Name:TOLONA
Authorized Official - Last Name:ATKINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-630-5037
Mailing Address - Street 1:3525 TORBAY DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28311-2462
Mailing Address - Country:US
Mailing Address - Phone:910-630-5037
Mailing Address - Fax:
Practice Address - Street 1:3525 TORBAY DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28311-2462
Practice Address - Country:US
Practice Address - Phone:910-630-5037
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3418208Medicaid