Basic Information
| Provider Information | |||||||||
| NPI: | 1629347398 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ONE LOVE PERIODIC SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 S STERLING ST | ||||||||
| Address2: | |||||||||
| City: | MORGANTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286553483 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8284334567 | ||||||||
| FaxNumber: | 8284334576 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 QUEEN ST | ||||||||
| Address2: | |||||||||
| City: | MORGANTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286553440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8284334567 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/23/2011 | ||||||||
| LastUpdateDate: | 01/16/2020 | ||||||||
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| AuthorizedOfficialLastName: | WIDEMAN | ||||||||
| AuthorizedOfficialFirstName: | STEVIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8284334567 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 01/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 8703220 | 05 | NC | MEDICAID | 8301457V | 05 | NC | MEDICAID | 5916270 | 05 | NC | MEDICAID | 3410218 | 05 | NC | MEDICAID | 6008242 | 05 | NC | MEDICAID | 8301457H | 05 | NC | MEDICAID |