Provider Demographics
NPI:1679027833
Name:ADDICTION RECOVERY MEDICAL SERVICES SUBSTANCE ABUSE FACILITY, LLC
Entity Type:Organization
Organization Name:ADDICTION RECOVERY MEDICAL SERVICES SUBSTANCE ABUSE FACILITY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:KEARNEY
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:704-872-0234
Mailing Address - Street 1:536 SIGNAL HILL DRIVE EXT
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28625-4391
Mailing Address - Country:US
Mailing Address - Phone:704-872-0234
Mailing Address - Fax:704-818-1115
Practice Address - Street 1:536 SIGNAL HILL DRIVE EXT
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28625-4391
Practice Address - Country:US
Practice Address - Phone:704-872-0234
Practice Address - Fax:704-818-1115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-05
Last Update Date:2016-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9300179261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89132YEMedicaid
NCE71204Medicare UPIN