Healthcare Provider Details

I. General information

NPI: 1629118013
Provider Name (Legal Business Name): WATERS' PROVIDER CARE SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 W JAMES ST
LA GRANGE NC
28551-1727
US

IV. Provider business mailing address

104 W JAMES ST
LA GRANGE NC
28551-1727
US

V. Phone/Fax

Practice location:
  • Phone: 252-566-3600
  • Fax:
Mailing address:
  • Phone: 252-566-3600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License NumberMHL-054-124
License Number StateNC

VIII. Authorized Official

Name: JOHN ERIC WATERS
Title or Position: SECRETARY - TREASURER
Credential:
Phone: 252-566-3600