Basic Information
| Provider Information | |||||||||
| NPI: | 1275614893 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY INNOVATIONS, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3210 FAIRHILL DR | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276123215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192560824 | ||||||||
| FaxNumber: | 9192560833 | ||||||||
| Practice Location | |||||||||
| Address1: | 410 PEANUT PLANT ROAD | ||||||||
| Address2: | |||||||||
| City: | ELIZABETHTOWN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283377103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9108628363 | ||||||||
| FaxNumber: | 9108628767 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2006 | ||||||||
| LastUpdateDate: | 12/17/2008 | ||||||||
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| AuthorizedOfficialLastName: | ANDERSON | ||||||||
| AuthorizedOfficialFirstName: | ANDY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER/CEO | ||||||||
| AuthorizedOfficialTelephone: | 9107398849 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COMMUNITY INNOVATIONS, INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | Y | Agencies | Case Management |
ID Information
| ID | Type | State | Issuer | Description | 8300962B | 05 | NC | MEDICAID |