Basic Information
| Provider Information | |||||||||
| NPI: | 1891850194 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRIDE IN NORTH CAROLINA, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PRIDE IN NORTH CAROLINA, LLC | ||||||||
| 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: | 1216 W CHURCH ST | ||||||||
| Address2: | |||||||||
| City: | ELIZABETH CITY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 279094612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2523310322 | ||||||||
| FaxNumber: | 2523310320 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2006 | ||||||||
| LastUpdateDate: | 10/04/2017 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RUTSKI | ||||||||
| AuthorizedOfficialFirstName: | JASON | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF BUSINESS OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 9104521460 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | N | Agencies | Community/Behavioral Health | 322D00000X | Y | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children |
ID Information
| ID | Type | State | Issuer | Description | 6604040 | 05 | NC | MEDICAID | 6603947 | 05 | NC | MEDICAID | 6603973 | 05 | NC | MEDICAID | 6603852 | 05 | NC | MEDICAID |