Basic Information
| Provider Information | |||||||||
| NPI: | 1154532596 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY INNOVATIONS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3210 FAIRHILL DR | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276123220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192560824 | ||||||||
| FaxNumber: | 9192568750 | ||||||||
| Practice Location | |||||||||
| Address1: | 704 PROGRESS PLACE | ||||||||
| Address2: | SUITE B | ||||||||
| City: | LAURINBURG | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283525545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102773212 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2007 | ||||||||
| LastUpdateDate: | 04/30/2008 | ||||||||
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| AuthorizedOfficialLastName: | ANDERSON | ||||||||
| AuthorizedOfficialFirstName: | ANDY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9106425697 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 5906100 | 05 | NC | MEDICAID |