Basic Information
| Provider Information | |||||||||
| NPI: | 1942608120 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CIHA JUVENILE SERVICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CIHA JUVENILE JUSTICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 HOSPITAL RD CALLER BOX C-268 | ||||||||
| Address2: | |||||||||
| City: | CHEROKEE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8284979163 | ||||||||
| FaxNumber: | 8284971723 | ||||||||
| Practice Location | |||||||||
| Address1: | 85 CHILDRENS HOME LOOP | ||||||||
| Address2: | |||||||||
| City: | CHEROKEE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8283596690 | ||||||||
| FaxNumber: | 8283590014 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2014 | ||||||||
| LastUpdateDate: | 12/14/2015 | ||||||||
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| AuthorizedOfficialLastName: | COOPER | ||||||||
| AuthorizedOfficialFirstName: | CASEY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8284979163 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CHEROKEE INDIAN HOSPITAL AUTHORITY | ||||||||
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| AuthorizedOfficialCredential: | CEO | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0855X | N | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 282N00000X | NC | N | Hospitals | General Acute Care Hospital | 103TC2200X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent |
ID Information
| ID | Type | State | Issuer | Description | 0767C | 01 | BCBSNC | OTHER | 3400156 | 05 | NC | MEDICAID | 0767C | 01 | NC | BCRS | OTHER |