NPIMap

Organization Active NPI

Robeson Health Care Corporation

Doing business as Crystal Lake

  • Community/Behavioral Health Agency
  • Lakeview, NC
National Provider Identifier
1689716607
Registry record updated Jun 28, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Behavioral Health AgencyTaxonomy code 251S00000X
License
MHL-063-055 Issued in NC
Legal business name
ROBESON HEALTH CARE CORPORATION
Doing business as
Crystal Lake
Practice address
285 Camp Easter Rd
Lakeview, NC 28350-1901
Phone
(910) 245-4339
Fax
(910) 245-4799
NPI assigned
Feb 13, 2007
Last updated
Jun 28, 2017By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 28, 2017

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Tim Hall, M.DIV.
Title
VP/Chief of Behavioral Health SVCS
Phone
(910) 521-2900

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Addiction (Substance Use Disorder) Counselor 101YA0400X MHL-063-055 NC
Community/Behavioral Health Agency 251S00000X MHL-063-055 NC Primary

Addresses

Primary practice location

285 Camp Easter Rd
Lakeview, NC 28350-1901

Mailing address

60 Commerce Drive
Pembroke, NC 28372
Phone (910) 521-2900

Other identifiers 6

IdentifierTypeStateIssuer
6005787MedicaidNC
8300803MedicaidNC
8300803GMedicaidNC
8300803PMedicaidNC
8300803BMedicaidNC
8300803QMedicaidNC

Other names 1

  • Crystal Lake Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NC

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20031231000292 NC Part B Supplier - Clinic/Group Practice 1850290693 Receives reassigned benefits from 27 practitioners
16 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Red Springs, NC; Smithfield, NC; Saint Pauls, NC; Pembroke, NC; Maxton, NC; Lumberton, NC; Fairmont, NC; Laurinburg, NC…

Other NPIs on the same Medicare enrollment 15

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

View all 15

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 8

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1171324800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1498608000000",
    "number": "1689716607",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "60 COMMERCE DRIVE",
            "city": "PEMBROKE",
            "state": "NC",
            "postal_code": "28372",
            "telephone_number": "910-521-2900",
            "fax_number": "910-272-1654"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "285 CAMP EASTER RD",
            "city": "LAKEVIEW",
            "state": "NC",
            "postal_code": "283501901",
            "telephone_number": "910-245-4339",
            "fax_number": "910-245-4799"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ROBESON HEALTH CARE CORPORATION",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-02-13",
        "last_updated": "2017-06-28",
        "status": "A",
        "authorized_official_last_name": "HALL",
        "authorized_official_first_name": "TIM",
        "authorized_official_title_or_position": "VP/CHIEF OF BEHAVIORAL HEALTH SVCS",
        "authorized_official_telephone_number": "910-521-2900",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "M.DIV."
    },
    "taxonomies": [
        {
            "code": "101YA0400X",
            "taxonomy_group": "",
            "desc": "Counselor, Addiction (Substance Use Disorder)",
            "state": "NC",
            "license": "MHL-063-055",
            "primary": false
        },
        {
            "code": "251S00000X",
            "taxonomy_group": "",
            "desc": "Community/Behavioral Health",
            "state": "NC",
            "license": "MHL-063-055",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "6005787",
            "state": "NC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "8300803",
            "state": "NC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "8300803G",
            "state": "NC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "8300803P",
            "state": "NC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "8300803B",
            "state": "NC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "8300803Q",
            "state": "NC"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Crystal Lake",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Lakeview, NC

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 28, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.