Healthcare Provider Details

I. General information

NPI: 1679682421
Provider Name (Legal Business Name): PHP OF NC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 05/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4125 BEN FRANKLIN BLVD SUITE 180
DURHAM NC
27704-2167
US

IV. Provider business mailing address

PO BOX 20014
DURHAM NC
27707-0027
US

V. Phone/Fax

Practice location:
  • Phone: 919-220-0021
  • Fax: 919-220-4555
Mailing address:
  • Phone: 919-220-0021
  • Fax: 919-220-4555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License NumberMHL-032-255
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License NumberHC1631
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberMHL-0320255
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License NumberMHL-032-255
License Number StateNC
# 5
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License NumberMHL-032-149
License Number StateNC
# 6
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License NumberMHL-032-245
License Number StateNC
# 7
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License NumberMHL-032-133
License Number StateNC
# 8
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License NumberMHL-032-349
License Number StateNC

VIII. Authorized Official

Name: JUSTINE WIGGINS
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 919-220-0021