Organization
TEEN SCENE ACT 3
Active
Organization subpart
No
Provider details
NPI number
Authorized official
CHANDA TRUESDELL (OWNER)
(704) 854-4840
Entity
Organization
Contact information
Practice address
114 B HOLLYCREST LANE, GASTONIA, NC 28056-9008
(704) 854-4840
Mailing address
708 S CHESTNUT ST, GASTONIA, NC 28054-4548
(704) 854-4840
Taxonomy
Speciality
Code
Description
License number
State
322D00000X
Emotionally Disturbed Childrens' Residential Treatment Facility
Primary
MHL-036-182
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
6604134
—
NC
Enumeration date
12/11/2007
Last updated
12/12/2007
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