Healthcare Provider Details

I. General information

NPI: 1548535107
Provider Name (Legal Business Name): NORTH CAROLINA ELDERLY PSYCHIATRIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2012
Last Update Date: 04/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

606 WADE AVE
RALEIGH NC
27605-1390
US

IV. Provider business mailing address

606 WADE AVE
RALEIGH NC
27605-1390
US

V. Phone/Fax

Practice location:
  • Phone: 919-443-2360
  • Fax: 919-800-3039
Mailing address:
  • Phone: 919-443-2360
  • Fax: 919-800-3039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. STEPHEN B MANGANO
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 919-443-2360