Basic Information
| Provider Information | |||||||||
| NPI: | 1285867952 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOOD TREATMENT CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1615 POLO RD | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271063859 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367227266 | ||||||||
| FaxNumber: | 3362010538 | ||||||||
| Practice Location | |||||||||
| Address1: | 1615 POLO RD | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271063859 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367227266 | ||||||||
| FaxNumber: | 3362010538 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2009 | ||||||||
| LastUpdateDate: | 08/28/2009 | ||||||||
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| AuthorizedOfficialLastName: | AIKEN | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
| AuthorizedOfficialMiddleName: | BRUNS | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3367227266 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 100934 | NC | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 2084P0800X | 200100996 | NC | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.