Basic Information
| Provider Information | |||||||||
| NPI: | 1316077043 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PORT HUMAN SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2245 STANTONSBURG RD | ||||||||
| Address2: | SUITE P | ||||||||
| City: | GREENVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278342868 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2527520483 | ||||||||
| FaxNumber: | 2527522971 | ||||||||
| Practice Location | |||||||||
| Address1: | 15 IRELAND DRIVE | ||||||||
| Address2: | |||||||||
| City: | BAYBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285150519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2527457789 | ||||||||
| FaxNumber: | 2527457647 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SAVIDGE | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2527520483 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 8300531 | 05 | NC | MEDICAID |