Basic Information
| Provider Information | |||||||||
| NPI: | 1437448750 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EASTER SEALS UCP NORTH CAROLINA & VIRGINIA, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5171 GLENWOOD AVE | ||||||||
| Address2: | STE 211 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276123266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197838898 | ||||||||
| FaxNumber: | 9197825486 | ||||||||
| Practice Location | |||||||||
| Address1: | 1142 NORTH ANDY GRIFFITH PARKWAY | ||||||||
| Address2: | |||||||||
| City: | MOUNT AIRY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 270302954 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367899492 | ||||||||
| FaxNumber: | 3367899587 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2011 | ||||||||
| LastUpdateDate: | 04/24/2017 | ||||||||
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| AuthorizedOfficialLastName: | KEY-ALLRED | ||||||||
| AuthorizedOfficialFirstName: | NASHEBA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CONTRACT SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 9197838898 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Community Health Worker | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 3408598 | 05 | NC | MEDICAID |