Healthcare Provider Details

I. General information

NPI: 1457472912
Provider Name (Legal Business Name): AMBLESIDE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 INDUSTRIAL DR
SNOW HILL NC
28580-1334
US

IV. Provider business mailing address

1 INDUSTRIAL DR
SNOW HILL NC
28580-1334
US

V. Phone/Fax

Practice location:
  • Phone: 252-747-5252
  • Fax: 252-747-4244
Mailing address:
  • Phone: 252-747-5252
  • Fax: 252-747-4244

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License NumberMHL-098-113
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier6603977
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

Name: DOUGLAS FINLEY
Title or Position: VP OPERATIONS
Credential:
Phone: 252-747-5252