Healthcare Provider Details

I. General information

NPI: 1659681567
Provider Name (Legal Business Name): EASTER SEALS UCP NORTH CAROLINA & VIRGINIA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2010
Last Update Date: 12/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2710 BURLWOOD DR
WINSTON SALEM NC
27103-6204
US

IV. Provider business mailing address

5171 GLENWOOD AVE SUITE 400
RALEIGH NC
27612-3266
US

V. Phone/Fax

Practice location:
  • Phone: 336-768-8823
  • Fax: 336-768-8550
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 Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

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