Basic Information
| Provider Information | |||||||||
| NPI: | 1619110582 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EASTER SEALS UCP NORTH CAROLINA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3801 LAKE BOONE TRL | ||||||||
| Address2: | SUITE 320 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276072934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9195384191 | ||||||||
| FaxNumber: | 9192560781 | ||||||||
| Practice Location | |||||||||
| Address1: | 33 DARLINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284031343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107905921 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2009 | ||||||||
| LastUpdateDate: | 04/08/2009 | ||||||||
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| AuthorizedOfficialLastName: | GERMANN | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9195384191 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.