Provider Demographics
NPI:1427814383
Name:SANKOFA 34 MENS HEALING HUB
Entity type:Organization
Organization Name:SANKOFA 34 MENS HEALING HUB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DERWIN
Authorized Official - Middle Name:SAMUEL
Authorized Official - Last Name:ISAIAH
Authorized Official - Suffix:II
Authorized Official - Credentials:LCMHC-S
Authorized Official - Phone:704-281-6356
Mailing Address - Street 1:1914 BRUNSWICK AVE STE 1B
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28207-1891
Mailing Address - Country:US
Mailing Address - Phone:704-281-6356
Mailing Address - Fax:910-973-0257
Practice Address - Street 1:1914 BRUNSWICK AVE STE 1B
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1891
Practice Address - Country:US
Practice Address - Phone:704-281-6356
Practice Address - Fax:910-973-0257
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-27
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)