Provider Demographics
NPI:1669858510
Name:CAROLINA OUTREACH, LLC
Entity Type:Organization
Organization Name:CAROLINA OUTREACH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-251-9001
Mailing Address - Street 1:5108 REAGAN DR STE 13&14
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28206-3103
Mailing Address - Country:US
Mailing Address - Phone:704-332-8787
Mailing Address - Fax:
Practice Address - Street 1:5108 REAGAN DR STE 13&14
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28206-3103
Practice Address - Country:US
Practice Address - Phone:704-332-8787
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CAROLINA OUTREACH, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-08-03
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health