MEDICARE: EXCHANGE CLUB CHILD ABUSE PREVENTION CENTER OF NORTH CAROLINA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1417045741
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EXCHANGE CLUB CHILD ABUSE PREVENTION CENTER OF NORTH CAROLINA

Provider Business Mailing Address
First Line	:	500 W NORTHWEST BLVD
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27105-6526
Country	:	US
Telephone Number	:	336-748-9028
Fax Number	:	336-748-9030

Provider Business Practice Location Address
First Line	:	500 W NORTHWEST BLVD
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27105-6526
Country	:	US
Telephone Number	:	336-748-9028
Fax Number	:	336-748-9030

Authorized Official
Title or Position	:	OPERATIONS MANAGER/COMPTROLLER
Name	:	MR. RICHARD PAUL BRODEUR
Credential	:
Telephone Number	:	336-748-9028

Provider Enumeration Date	:	10/11/2006
Last Update Date	:	08/22/2020

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