Basic Information
| Provider Information | |||||||||
| NPI: | 1881834653 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EASTER SEALS UCP NORTH CAROLINA& VIRGINIA, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5171 GLENWOOD AVE | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276123266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197838898 | ||||||||
| FaxNumber: | 9197825486 | ||||||||
| Practice Location | |||||||||
| Address1: | 1503 WAYNE MEMORIAL DR | ||||||||
| Address2: | UNIT E | ||||||||
| City: | GOLDSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275342203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9195870001 | ||||||||
| FaxNumber: | 9195870007 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2009 | ||||||||
| LastUpdateDate: | 11/20/2015 | ||||||||
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| AuthorizedOfficialLastName: | EDWARDS | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | CONTRACT ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9197838898 | ||||||||
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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 | N | Agencies | Case Management | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 8300746B | 05 | NC | MEDICAID | 8300746F | 05 | NC | MEDICAID | 8300746I | 05 | NC | MEDICAID | 8300746H | 05 | NC | MEDICAID |