Basic Information
| Provider Information | |||||||||
| NPI: | 1477845873 | ||||||||
| 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: | 9192568750 | ||||||||
| Practice Location | |||||||||
| Address1: | 328 E 24TH ST | ||||||||
| Address2: | |||||||||
| City: | LUMBERTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283583102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107376440 | ||||||||
| FaxNumber: | 9107376499 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2011 | ||||||||
| LastUpdateDate: | 05/04/2011 | ||||||||
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| AuthorizedOfficialLastName: | ANDERSON | ||||||||
| AuthorizedOfficialFirstName: | ANDY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9107398849 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | MHL078270 | NC | Y | Agencies | Community/Behavioral Health |
No ID Information.