Provider Demographics
NPI:1700167350
Name:REALISTIC CHANGE BY C.H.O.I.C.E. @ WINCHESTER II
Entity Type:Organization
Organization Name:REALISTIC CHANGE BY C.H.O.I.C.E. @ WINCHESTER II
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR, C.E.O.
Authorized Official - Prefix:MRS
Authorized Official - First Name:RHONDA
Authorized Official - Middle Name:
Authorized Official - Last Name:CORPENING
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:704-528-2044
Mailing Address - Street 1:PO BOX 570
Mailing Address - Street 2:
Mailing Address - City:TROUTMAN
Mailing Address - State:NC
Mailing Address - Zip Code:28166-0570
Mailing Address - Country:US
Mailing Address - Phone:704-528-2044
Mailing Address - Fax:704-528-2077
Practice Address - Street 1:320 WINCHESTER RD
Practice Address - Street 2:
Practice Address - City:TROUTMAN
Practice Address - State:NC
Practice Address - Zip Code:28166-9644
Practice Address - Country:US
Practice Address - Phone:704-528-2044
Practice Address - Fax:704-528-2077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-08
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL 049-132320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC45239256OtherEIN