Provider Demographics
NPI:1922541671
Name:POURING 4 PURPOSE, LLC
Entity Type:Organization
Organization Name:POURING 4 PURPOSE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:DRAKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-306-2200
Mailing Address - Street 1:1416 BETHLEHEM RD
Mailing Address - Street 2:
Mailing Address - City:HARTSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29550-1716
Mailing Address - Country:US
Mailing Address - Phone:336-306-2200
Mailing Address - Fax:
Practice Address - Street 1:1416 BETHLEHEM RD
Practice Address - Street 2:
Practice Address - City:HARTSVILLE
Practice Address - State:SC
Practice Address - Zip Code:29550-1716
Practice Address - Country:US
Practice Address - Phone:843-250-6679
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-29
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty