Healthcare Provider Details

I. General information

NPI: 1013196948
Provider Name (Legal Business Name): INFANTS, CHILDREN, ADULTS, ADOLESCENTS/JUVENILES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2007
Last Update Date: 03/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2707 N ROXBORO ST
DURHAM NC
27704-4351
US

IV. Provider business mailing address

PO BOX 15928
DURHAM NC
27704-0928
US

V. Phone/Fax

Practice location:
  • Phone: 919-201-0052
  • Fax:
Mailing address:
  • Phone:
  • Fax: 919-283-0005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. ALICIA MICHELLE ELDER
Title or Position: OWNER/CEO
Credential: BBA, QP
Phone: 919-201-0052