Healthcare Provider Details

I. General information

NPI: 1649316639
Provider Name (Legal Business Name): EASTER SEALS UCP NORTH CAROLINA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 03/09/2021
Certification Date: 03/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2315 MYRON DR
RALEIGH NC
27607
US

IV. Provider business mailing address

5700 EXECUTIVE CENTER DR SUITE 110
CHARLOTTE NC
28212-8858
US

V. Phone/Fax

Practice location:
  • Phone: 704-566-6040
  • Fax: 704-971-2537
Mailing address:
  • Phone: 704-566-6040
  • Fax: 704-971-2537

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 Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State

VIII. Authorized Official

Name: NASHEBA KEY-ALLRED
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 919-865-8632