Basic Information
| Provider Information | |||||||||
| NPI: | 1225222516 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHILDREN'S HEALTH OF CAROLINA, DBA LUMBERTON CHILDREN'S CLINIC MENTAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 LIBERTY HILL RD | ||||||||
| Address2: | |||||||||
| City: | LUMBERTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283582446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107388060 | ||||||||
| FaxNumber: | 9106713600 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 LIBERTY HILL RD | ||||||||
| Address2: | |||||||||
| City: | LUMBERTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283582446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107388060 | ||||||||
| FaxNumber: | 9106713600 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2007 | ||||||||
| LastUpdateDate: | 08/30/2007 | ||||||||
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| AuthorizedOfficialLastName: | DUCKWORTH | ||||||||
| AuthorizedOfficialFirstName: | ROSE | ||||||||
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| AuthorizedOfficialTitleorPosition: | COMPLIANCE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9107388060 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 8902032 | 05 | NC | MEDICAID |