Basic Information
| Provider Information | |||||||||
| NPI: | 1770621526 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRIDE IN NORTH CAROLINA, LLC | ||||||||
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| OtherOrganizationName: | PRIDE IN NORTH CAROLINA, INC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 231 COMMERCE ST | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278585029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2523218080 | ||||||||
| FaxNumber: | 2523217999 | ||||||||
| Practice Location | |||||||||
| Address1: | 2815 S CHURCH ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272155105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3365860647 | ||||||||
| FaxNumber: | 3365860729 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2007 | ||||||||
| LastUpdateDate: | 10/04/2017 | ||||||||
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| AuthorizedOfficialLastName: | RUTSKI | ||||||||
| AuthorizedOfficialFirstName: | JASON | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF BUSINESS OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 9104521460 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 2084P0800X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 8300581 | 05 | NC | MEDICAID | 8300581B | 05 | NC | MEDICAID | 8300581G | 05 | NC | MEDICAID |