Healthcare Provider Details

I. General information

NPI: 1952616583
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: 08/06/2010
Last Update Date: 11/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

318 GRANT ST
SPENCER NC
28159-1676
US

IV. Provider business mailing address

5171 GLENWOOD AVE SUITE 400
RALEIGH NC
27612-3266
US

V. Phone/Fax

Practice location:
  • Phone: 704-647-0094
  • Fax: 704-636-7427
Mailing address:
  • Phone: 919-783-8898
  • Fax: 919-782-5486

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code311Z00000X
TaxonomyCustodial Care Facility
License Number
License Number State

VIII. Authorized Official

Name: RICHARD EDWARDS
Title or Position: CONTRACT ADMINISTRATOR
Credential:
Phone: 919-783-8898