Basic Information
| Provider Information | |||||||||
| NPI: | 1598070039 | ||||||||
| 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: | SUITE 400 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276123266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197838898 | ||||||||
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| Practice Location | |||||||||
| Address1: | 603 LONG ST | ||||||||
| Address2: | |||||||||
| City: | WEST JEFFERSON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286948810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362466504 | ||||||||
| FaxNumber: | 3362466504 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2010 | ||||||||
| LastUpdateDate: | 09/24/2018 | ||||||||
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| AuthorizedOfficialLastName: | KEY-ALLRED | ||||||||
| AuthorizedOfficialFirstName: | NASHEBA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 9198658632 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | N | Agencies | Community/Behavioral Health | 3104A0625X | Y | Nursing & Custodial Care Facilities | Assisted Living Facility | Assisted Living, Mental Illness |
No ID Information.