Basic Information
| Provider Information | |||||||||
| NPI: | 1124163639 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COUNTY OF CLEVELAND NORTH CAROLINA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CLEVELAND CO. HEALTH DEPT CA CASE MGMT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 315 E GROVER ST | ||||||||
| Address2: | |||||||||
| City: | SHELBY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281503919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7044845100 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 315 E GROVER ST | ||||||||
| Address2: | |||||||||
| City: | SHELBY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281503919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7044845100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2007 | ||||||||
| LastUpdateDate: | 05/24/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WYANT | ||||||||
| AuthorizedOfficialFirstName: | DOROTHEA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | HEALTH DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7044845100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COUNTY OF CLEVELAND NORTH CAROLINA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | N | Agencies | Case Management | 261QP0905X | Y | Ambulatory Health Care Facilities | Clinic/Center | Public Health, State or Local |
ID Information
| ID | Type | State | Issuer | Description | 6701010 | 05 | NC | MEDICAID |