Basic Information
| Provider Information | |||||||||
| NPI: | 1114197993 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NEW RIVER SERVICE AUTHORITY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NEW RIVER BEHAVIORAL HEALTHCARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 895 STATE FARM RD | ||||||||
| Address2: | SUITE 508 | ||||||||
| City: | BOONE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286074917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282635666 | ||||||||
| FaxNumber: | 8282625687 | ||||||||
| Practice Location | |||||||||
| Address1: | 320 E LEE AVE | ||||||||
| Address2: | |||||||||
| City: | YADKINVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 270558132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3366798805 | ||||||||
| FaxNumber: | 8282625687 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2008 | ||||||||
| LastUpdateDate: | 03/07/2008 | ||||||||
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| AuthorizedOfficialLastName: | ANDREWS | ||||||||
| AuthorizedOfficialFirstName: | PATRICIA | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3363724095 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LPC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 2329286 | 01 | NC | MEDICARE | OTHER |