Basic Information
| Provider Information | |||||||||
| NPI: | 1841377926 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY INNOVATIONS INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | TIMBERLEA GROUP HOME | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3210 FAIRHILL DR | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276123220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192560824 | ||||||||
| FaxNumber: | 9192568750 | ||||||||
| Practice Location | |||||||||
| Address1: | 5691 MACK LINEBERRY ROAD | ||||||||
| Address2: | |||||||||
| City: | CLIMAX | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272338076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3366854955 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 07/26/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JONES | ||||||||
| AuthorizedOfficialFirstName: | HAROLD | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9192560824 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 315P00000X | MHL076023 | NC | Y | Nursing & Custodial Care Facilities | Intermediate Care Facility, Mentally Retarded |
ID Information
| ID | Type | State | Issuer | Description | 340608T | 05 | NC | MEDICAID |