Basic Information
| Provider Information | |||||||||
| NPI: | 1144375767 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OCTOBER ROAD INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 119 TUNNEL RD | ||||||||
| Address2: | SUITE D | ||||||||
| City: | ASHEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 288051869 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8283501000 | ||||||||
| FaxNumber: | 8283501300 | ||||||||
| Practice Location | |||||||||
| Address1: | 119 TUNNEL RD STE B | ||||||||
| Address2: | |||||||||
| City: | ASHEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 288051800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8283501000 | ||||||||
| FaxNumber: | 8283501300 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2007 | ||||||||
| LastUpdateDate: | 05/03/2018 | ||||||||
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| AuthorizedOfficialLastName: | HUSTED | ||||||||
| AuthorizedOfficialFirstName: | CHAD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF NC OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 8283501000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | BA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | MLH-011-272 | NC | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 3410004 | 05 | NC | MEDICAID | 8703016 | 05 | NC | MEDICAID | 5905845 | 05 | NC | MEDICAID | 8305312 | 05 | NC | MEDICAID | 6006159 | 05 | NC | MEDICAID | MHL-011-272 | 01 | NC DHSR | OTHER |