Healthcare Provider Details

I. General information

NPI: 1902944671
Provider Name (Legal Business Name): PRIDE IN NORTH CAROLINA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 10/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 WEST CHURCH STREET EXT
ELIZABETH CITY NC
27909-4510
US

IV. Provider business mailing address

231 COMMERCE ST
GREENVILLE NC
27858-5029
US

V. Phone/Fax

Practice location:
  • Phone: 252-321-0322
  • Fax: 252-331-0320
Mailing address:
  • Phone: 252-321-8080
  • Fax: 252-321-7999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. JASON RUTSKI
Title or Position: DIRECTOR OF BUSINESS OPERATIONS
Credential:
Phone: 910-452-1460