| Deep River Psychiatric Group Pllc | |
|
301 King St Apt 1e Greensboro NC 27406-1699 | |
| (919) 630-5144 | |
| Not Available |
| Full Name | Deep River Psychiatric Group Pllc |
|---|---|
| Speciality | Community/Behavioral Health |
| Location | 301 King St Apt 1e, Greensboro, North Carolina |
| Authorized Official Name and Position | Allan M Faircloth (CEO) |
| Authorized Official Contact | 9196305144 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Deep River Psychiatric Group Pllc 301 King St Apt 1e Greensboro NC 27406-1699 Ph: (919) 630-5144 | Deep River Psychiatric Group Pllc 301 King St Apt 1e Greensboro NC 27406-1699 Ph: (919) 630-5144 |
| NPI Number | 1760172555 |
|---|---|
| Provider Enumeration Date | 05/15/2023 |
| Last Update Date | 05/15/2023 |
| Certification Date | 05/14/2023 |
| Medicare PECOS PAC ID | 1951764265 |
|---|---|
| Medicare Enrollment ID | O20230901002205 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1760172555 | NPI | - | NPPES |
| 1457876591 | Other | NC | MEDICARE |
| 1457876571 | Medicaid | NC |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 101YA0400X | Counselor - Addiction (substance Use Disorder) | (* (Not Available)) | Secondary |
| 251S00000X | Community/behavioral Health | (* (Not Available)) | Primary |
| Provider Name | Kristen King |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1740845528 PECOS PAC ID: 8022344951 Enrollment ID: I20190730001871 |
| Provider Name | Allan Marcos Faircloth |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1457876591 PECOS PAC ID: 1951796176 Enrollment ID: I20220324001305 |
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