Basic Information
| Provider Information | |||||||||
| NPI: | 1346395415 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DAYMARK RECOVERY SERVICES, 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: | 651 HIGHLAND AVE | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271014303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3366578523 | ||||||||
| FaxNumber: | 3367230645 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2007 | ||||||||
| LastUpdateDate: | 04/04/2008 | ||||||||
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| AuthorizedOfficialLastName: | WEST | ||||||||
| AuthorizedOfficialFirstName: | BILLY | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7049391100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | L.C.S.W. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 284300000X | MHL-034-002 | NC | Y | Hospitals | Special Hospital |
ID Information
| ID | Type | State | Issuer | Description | 8300314 | 05 | NC | MEDICAID |