Basic Information
| Provider Information | |||||||||
| NPI: | 1275969230 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EASTER SEALS UCP NORTH CAROLINA & VIRGINIA | ||||||||
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| Address1: | 5171 GLENWOOD AVE | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276123266 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 511 WILSON AVE | ||||||||
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| City: | SPRING LAKE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283903648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197838898 | ||||||||
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| ProviderEnumerationDate: | 09/23/2013 | ||||||||
| LastUpdateDate: | 01/15/2014 | ||||||||
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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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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080A0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine |
No ID Information.