Basic Information
| Provider Information | |||||||||
| NPI: | 1528314903 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | METROPOLITAN HOMECARE AND BEHAVIORAL SERVICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | METROPOLITAN HOMECARE AND BEHAVIORAL SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 120 W MARTIN LUTHER KING JR DR | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278894906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2529400602 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 120 W MARTIN LUTHER KING JR DR | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278894906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2529400602 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2012 | ||||||||
| LastUpdateDate: | 08/06/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MOORE | ||||||||
| AuthorizedOfficialFirstName: | MELINDA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2529400600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | METROPOLITAN COMMUNITY HEALTH SERVICES | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 302F00000X | 0000000000 | NC | N | Managed Care Organizations | Exclusive Provider Organization | 305S00000X | 00000000 | NC | N | Managed Care Organizations | Point of Service | 302R00000X | 000000000 | NC | Y | Managed Care Organizations | Health Maintenance Organization |
ID Information
| ID | Type | State | Issuer | Description | 000000000 | 05 | NC | MEDICAID |