Healthcare Provider Details

I. General information

NPI: 1811288574
Provider Name (Legal Business Name): EASTER SEALS UCP NORTH CAROLINA & VIRGINIA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2011
Last Update Date: 09/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 MOCKINGBIRD LN
WILMINGTON NC
28409-5617
US

IV. Provider business mailing address

5171 GLENWOOD AVE SUITE 400
RALEIGH NC
27612-3266
US

V. Phone/Fax

Practice location:
  • Phone: 910-313-6653
  • Fax:
Mailing address:
  • Phone: 919-783-8898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License NumberMHL-065-223
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

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