Provider Demographics
NPI:1316142771
Name:CHERRY, ALBERT DOMINIQUE
Entity type:Individual
Prefix:
First Name:ALBERT
Middle Name:DOMINIQUE
Last Name:CHERRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:741 EDENBROOK DR
Mailing Address - Street 2:
Mailing Address - City:WINTERVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28590-7101
Mailing Address - Country:US
Mailing Address - Phone:252-355-1881
Mailing Address - Fax:252-345-1310
Practice Address - Street 1:743 CHARLES TAYLOR RD
Practice Address - Street 2:
Practice Address - City:AULANDER
Practice Address - State:NC
Practice Address - Zip Code:27805-9690
Practice Address - Country:US
Practice Address - Phone:252-794-2269
Practice Address - Fax:252-345-1310
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL008002171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator