Basic Information
| Provider Information | |||||||||
| NPI: | 1871508408 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NC DEPT OF MILITARY AND VETERANS AFFAIRS NC DIVISION OF VETERANS AFFAI | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4001 MAIL SERVICE CTR | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276994001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9842042990 | ||||||||
| FaxNumber: | 9842048344 | ||||||||
| Practice Location | |||||||||
| Address1: | 214 COCHRAN AVE | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283013875 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104824131 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2006 | ||||||||
| LastUpdateDate: | 06/15/2022 | ||||||||
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| AuthorizedOfficialLastName: | WESTBROOK | ||||||||
| AuthorizedOfficialFirstName: | TERRY | ||||||||
| AuthorizedOfficialMiddleName: | EDWARD | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF VETERANS SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 9842042982 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | NH0585 | NC | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0086A | 01 | NC | BCBS | OTHER | 3405492 | 05 | NC | MEDICAID |