Basic Information
| Provider Information | |||||||||
| NPI: | 1780756056 | ||||||||
| 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: | 1503 S GLEN BURNIE ROAD | ||||||||
| Address2: | |||||||||
| City: | NEW BERN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285621503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2526381028 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | ANDERSON | ||||||||
| AuthorizedOfficialFirstName: | ANDY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9107398849 | ||||||||
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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 | 251B00000X | Y | Agencies | Case Management |
ID Information
| ID | Type | State | Issuer | Description | 8300965 | 05 | NC | MEDICAID |