Basic Information
| Provider Information | |||||||||
| NPI: | 1396885711 | ||||||||
| 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: | 280251833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7049391100 | ||||||||
| FaxNumber: | 7049391173 | ||||||||
| Practice Location | |||||||||
| Address1: | 1104 A SOUTH MAIN ST | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272923134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362422450 | ||||||||
| FaxNumber: | 3362499920 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2007 | ||||||||
| LastUpdateDate: | 09/01/2016 | ||||||||
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| AuthorizedOfficialLastName: | WEST | ||||||||
| AuthorizedOfficialFirstName: | BILLY | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7049391100 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional | 103TC0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 106H00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 261QM1300X | MHL-029-032 | NC | N | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 101YM0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 6005707 | 05 | NC | MEDICAID |