Basic Information
| Provider Information | |||||||||
| NPI: | 1679643373 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY INNOVATIONS, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2003 GODWIN AVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | LUMBERTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283583197 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107398849 | ||||||||
| FaxNumber: | 9107398698 | ||||||||
| Practice Location | |||||||||
| Address1: | 1781 SOUTH MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | LAURINBURG | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102773212 | ||||||||
| FaxNumber: | 9102773214 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2006 | ||||||||
| LastUpdateDate: | 10/21/2011 | ||||||||
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| AuthorizedOfficialLastName: | ANDERSON | ||||||||
| AuthorizedOfficialFirstName: | ANDY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9107938849 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | NC | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | NC | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional | 1041C0700X | NC | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 2084P0800X | NC | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 171M00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 8300959 | 05 | NC | MEDICAID |