Basic Information
| Provider Information | |||||||||
| NPI: | 1740474543 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FUNDAMENTAL HEALTH RESOURCES INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 28887 | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276118887 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9195396661 | ||||||||
| FaxNumber: | 0000000000 | ||||||||
| Practice Location | |||||||||
| Address1: | 4816 LOGANSHIRE LN | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276162974 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9195396661 | ||||||||
| FaxNumber: | 0000000000 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2007 | ||||||||
| LastUpdateDate: | 09/05/2007 | ||||||||
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| AuthorizedOfficialLastName: | WOODS | ||||||||
| AuthorizedOfficialFirstName: | KWAME | ||||||||
| AuthorizedOfficialMiddleName: | KAMALA | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9195396661 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | BA CSAC-R QP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 104100000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | 251B00000X | N | Agencies | Case Management | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.