Basic Information
Provider Information | |||||||||
NPI: | 1285863407 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DAYMARK RECOVERY SERVICES INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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: | 335 COUNTY HOME RD | ||||||||
Address2: |   | ||||||||
City: | REIDSVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 273209694 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3363428316 | ||||||||
FaxNumber: | 3363428352 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/09/2009 | ||||||||
LastUpdateDate: | 12/21/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WEST | ||||||||
AuthorizedOfficialFirstName: | BILLY | ||||||||
AuthorizedOfficialMiddleName: | R | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 7049391100 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: | JR. | ||||||||
AuthorizedOfficialCredential: | M.S.W., L.C.S.W. | ||||||||
NPICertificationDate: | 12/21/2020 |
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 | 5912830 | 05 | NC |   | MEDICAID |