Provider Demographics
NPI:1790097525
Name:MYRIAD SUPPORT CENTER
Entity Type:Organization
Organization Name:MYRIAD SUPPORT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:YUSSEF
Authorized Official - Middle Name:LATEEF
Authorized Official - Last Name:GILKEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-575-2002
Mailing Address - Street 1:3540 VEST MILL RD STE 6
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-2988
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3540 VEST MILL RD STE 6
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-2988
Practice Address - Country:US
Practice Address - Phone:336-602-2940
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SURRENT CAPITAL, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-07-09
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty