Basic Information
| Provider Information | |||||||||
| NPI: | 1477646081 | ||||||||
| 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: | 4000 WAKE FOREST ROAD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198611600 | ||||||||
| FaxNumber: | 9198611637 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 10/04/2018 | ||||||||
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| AuthorizedOfficialLastName: | LITTLE | ||||||||
| AuthorizedOfficialFirstName: | JELORE | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR, CONTRACTS & CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 3365456338 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 322D00000X | N | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children | 385HR2055X | N | Respite Care Facility | Respite Care | Respite Care, Mental Illness, Child | 385HR2060X | N | Respite Care Facility | Respite Care | Respite Care, Mental Retardation and/or Developmental Disabilities, Child | 385HR2065X | N | Respite Care Facility | Respite Care | Respite Care, Physical Disabilities, Child | 251B00000X | N | Agencies | Case Management | 251C00000X | N | Agencies | Day Training, Developmentally Disabled Services | 251F00000X | N | Agencies | Home Infusion | 261QD1600X | N | Ambulatory Health Care Facilities | Clinic/Center | Developmental Disabilities | 261QH0700X | N | Ambulatory Health Care Facilities | Clinic/Center | Hearing and Speech | 261QP2000X | N | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy | 261QX0100X | N | Ambulatory Health Care Facilities | Clinic/Center | Occupational Medicine | 320900000X | N | Residential Treatment Facilities | Community Based Residential Treatment, Mental Retardation and/or Developmental Disabilities | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.