Basic Information
| Provider Information | |||||||||
| NPI: | 1932470838 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EASTER SEALS UCP NORTH CAROLINA & VIRGINIA, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10150 MALLARD CREEK RD | ||||||||
| Address2: | SUITE 510 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282629708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043338220 | ||||||||
| FaxNumber: | 7049712537 | ||||||||
| Practice Location | |||||||||
| Address1: | 622 BASS LN | ||||||||
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| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282702231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7042465417 | ||||||||
| FaxNumber: | 7043218234 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2012 | ||||||||
| LastUpdateDate: | 01/24/2012 | ||||||||
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| AuthorizedOfficialLastName: | EDWARDS | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9197838898 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 311ZA0620X | Y | Nursing & Custodial Care Facilities | Custodial Care Facility | Adult Care Home |
No ID Information.