Basic Information
| Provider Information | |||||||||
| NPI: | 1174669188 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EASTER SEALS UCP NORTH CAROLINA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5700 EXECUTIVE CENTER DR | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282128858 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7045666040 | ||||||||
| FaxNumber: | 7049712537 | ||||||||
| Practice Location | |||||||||
| Address1: | 704 SE 2ND ST | ||||||||
| Address2: | |||||||||
| City: | SNOW HILL | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285801631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7045666040 | ||||||||
| FaxNumber: | 7049712537 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2007 | ||||||||
| LastUpdateDate: | 09/16/2013 | ||||||||
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| AuthorizedOfficialLastName: | EDWARDS | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP | ||||||||
| AuthorizedOfficialTelephone: | 9197838898 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 311ZA0620X | Y | Nursing & Custodial Care Facilities | Custodial Care Facility | Adult Care Home |
ID Information
| ID | Type | State | Issuer | Description | 7801319 | 05 | NC | MEDICAID |