Basic Information
| Provider Information | |||||||||
| NPI: | 1164576898 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EASTER SEALS UCP NORTH CAROLINA & VIRGINIA, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5171 GLENWOOD AVE | ||||||||
| Address2: | SUITE 211 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276123266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197838898 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4130 OLEANDER DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284036843 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107905921 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2007 | ||||||||
| LastUpdateDate: | 04/21/2017 | ||||||||
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| AuthorizedOfficialLastName: | KEY-ALLRED | ||||||||
| AuthorizedOfficialFirstName: | NASHEBA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CONTRACT ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9197838898 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | N | Agencies | Case Management | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 8300592A | 05 | NC | MEDICAID | 8300592H | 05 | NC | MEDICAID | 8300592B | 05 | NC | MEDICAID | 8300592I | 05 | NC | MEDICAID | 8300592G | 05 | NC | MEDICAID |