Provider Demographics
NPI:1306039904
Name:MYRIAD SUPPORT CENTER INCORPORATED
Entity type:Organization
Organization Name:MYRIAD SUPPORT CENTER INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:YUSSEF
Authorized Official - Middle Name:LATEEF
Authorized Official - Last Name:GILKEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-896-2550
Mailing Address - Street 1:3500 VEST MILL RD
Mailing Address - Street 2:SUITE 9
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-2978
Mailing Address - Country:US
Mailing Address - Phone:336-890-2550
Mailing Address - Fax:336-217-8009
Practice Address - Street 1:3500 VEST MILL RD
Practice Address - Street 2:SUITE 9
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-2978
Practice Address - Country:US
Practice Address - Phone:336-896-2550
Practice Address - Fax:336-217-8009
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SURRENT CAPITAL INCORPORATED
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-27
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health