Basic Information
| Provider Information | |||||||||
| NPI: | 1043596331 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DAYMARK RECOVERY SERVICE INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 284 EXECUTIVE PARK DRIVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CONCORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280251894 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7049391100 | ||||||||
| FaxNumber: | 7049391173 | ||||||||
| Practice Location | |||||||||
| Address1: | 320 E LEE AVE | ||||||||
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| City: | YADKINVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 270558132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3366798805 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2011 | ||||||||
| LastUpdateDate: | 03/03/2015 | ||||||||
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| AuthorizedOfficialLastName: | WEST | ||||||||
| AuthorizedOfficialFirstName: | BILLY | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7049391100 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | M.S.W.,L.C.S.W. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 3410027 | 05 | NC | MEDICAID |