Basic Information
Provider Information | |||||||||
NPI: | 1659532562 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NEW RIVER SERVICE AUTHORITY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | NEW RIVER BEHAVIORAL HEALTHCARE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 895 STATE FARM RD | ||||||||
Address2: | SUITE 508 | ||||||||
City: | BOONE | ||||||||
State: | NC | ||||||||
PostalCode: | 286074917 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8282635666 | ||||||||
FaxNumber: | 8282625687 | ||||||||
Practice Location | |||||||||
Address1: | 2415 MORGANTON BLVD SW | ||||||||
Address2: |   | ||||||||
City: | LENOIR | ||||||||
State: | NC | ||||||||
PostalCode: | 286459691 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8287575685 | ||||||||
FaxNumber: | 8287574581 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/23/2008 | ||||||||
LastUpdateDate: | 06/24/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ANDREWS | ||||||||
AuthorizedOfficialFirstName: | PAMELA | ||||||||
AuthorizedOfficialMiddleName: | P | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 3363724095 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X |   |   | Y |   | Agencies | Community/Behavioral Health |   |
No ID Information.