Healthcare Provider Details

I. General information

NPI: 1982919668
Provider Name (Legal Business Name): EASTER SEALS UCP OF NORTH CAROLINA & VIRGINIA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2010
Last Update Date: 08/20/2021
Certification Date: 08/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

89 ASHLYN DR SE
CONCORD NC
28025-3546
US

IV. Provider business mailing address

5171 GLENWOOD AVE SUITE 400
RALEIGH NC
27612-3266
US

V. Phone/Fax

Practice location:
  • Phone: 704-721-5912
  • Fax: 704-721-5913
Mailing address:
  • Phone: 919-783-8898
  • Fax: 919-782-5486

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code311Z00000X
TaxonomyCustodial Care Facility
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: NASHEBA KEY-ALLRED
Title or Position: CONTRACT ADMINISTRATOR
Credential:
Phone: 919-783-8898