Organization
CLUB NOVA COMMUNITY, INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JACOB LONG (ASSOCIATE DIRECTOR OF ADMINISTRATIO)
(919) 968-6682
Entity
Organization
Contact information
Practice address
103 W MAIN ST, SUITE D, CARRBORO, NC 27510-2072
(919) 968-6682
(919) 968-1764
Mailing address
103 W MAIN ST, SUITE D, CARRBORO, NC 27510-2072
(919) 968-6682
(919) 968-1764
Taxonomy
Speciality
Code
Description
License number
State
261QM0850X
Adult Mental Health Clinic/Center
Primary
MHL068017
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
8301156S
—
NC
Enumeration date
12/18/2006
Last updated
09/14/2007
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