Basic Information
| Provider Information | |||||||||
| NPI: | 1669086948 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OCTOBER ROAD, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 119 TUNNEL RD STE D | ||||||||
| Address2: | |||||||||
| City: | ASHEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 288051800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8283501000 | ||||||||
| FaxNumber: | 8283501300 | ||||||||
| Practice Location | |||||||||
| Address1: | 1304 PLAZA DR STE 2312 | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272157165 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8283501000 | ||||||||
| FaxNumber: | 8283501300 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/03/2020 | ||||||||
| LastUpdateDate: | 09/03/2020 | ||||||||
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| AuthorizedOfficialLastName: | HUSTED | ||||||||
| AuthorizedOfficialFirstName: | CHAD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP | ||||||||
| AuthorizedOfficialTelephone: | 8283501000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 09/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 8305312 | 05 | NC | MEDICAID |