Healthcare Provider Details

I. General information

NPI: 1306781158
Provider Name (Legal Business Name): INTEGRATED CARE SUPPORT SVCS NC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2026
Last Update Date: 04/20/2026
Certification Date: 04/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

96031 BROADMOOR RD
FERNANDINA BEACH FL
32034
US

IV. Provider business mailing address

96031 BROADMOOR RD
FERNANDINA BEACH FL
32034
US

V. Phone/Fax

Practice location:
  • Phone: 704-929-8119
  • Fax:
Mailing address:
  • Phone: 704-929-8119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: KRISTY PAVELOCK
Title or Position: QUALIFIED PROFESSIONAL/CASE MANAGER
Credential: B.A.
Phone: 704-929-8119