Healthcare Provider Details

I. General information

NPI: 1982919429
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: 08/09/2010
Last Update Date: 06/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1125 FAIRVIEW DR SW A
LENOIR NC
28645-6082
US

IV. Provider business mailing address

5171 GLENWOOD AVE SUITE 400
RALEIGH NC
27612-3266
US

V. Phone/Fax

Practice location:
  • Phone: 828-757-0005
  • Fax: 828-757-0025
Mailing address:
  • Phone: 919-783-8898
  • Fax: 919-782-5486

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

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