Basic Information
| Provider Information | |||||||||
| NPI: | 1720272826 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY ALTERNATIVE HOUSING INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 87195 | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283047195 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104868989 | ||||||||
| FaxNumber: | 9108263695 | ||||||||
| Practice Location | |||||||||
| Address1: | 2905 BREEZEWOOD AVE | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283035503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104868989 | ||||||||
| FaxNumber: | 9108263695 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2007 | ||||||||
| LastUpdateDate: | 04/10/2014 | ||||||||
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| AuthorizedOfficialLastName: | NICHOLS | ||||||||
| AuthorizedOfficialFirstName: | WILBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9104868989 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | LPCA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 8700455 | 05 | NC | MEDICAID |