Provider Demographics
NPI:1689716607
Name:ROBESON HEALTH CARE CORPORATION
Entity Type:Organization
Organization Name:ROBESON HEALTH CARE CORPORATION
Other - Org Name:CRYSTAL LAKE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP/CHIEF OF BEHAVIORAL HEALTH SVCS
Authorized Official - Prefix:MR
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:MDIV
Authorized Official - Phone:910-521-2900
Mailing Address - Street 1:60 COMMERCE DRIVE
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE
Mailing Address - State:NC
Mailing Address - Zip Code:28372
Mailing Address - Country:US
Mailing Address - Phone:910-521-2900
Mailing Address - Fax:910-272-1654
Practice Address - Street 1:285 CAMP EASTER RD
Practice Address - Street 2:
Practice Address - City:LAKEVIEW
Practice Address - State:NC
Practice Address - Zip Code:28350-1901
Practice Address - Country:US
Practice Address - Phone:910-245-4339
Practice Address - Fax:910-245-4799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2017-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-063-055101YA0400X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8300803PMedicaid
NC8300803QMedicaid
NC8300803Medicaid
NC6005787Medicaid
NC8300803BMedicaid
NC8300803GMedicaid
NC2804358Medicare PIN