Healthcare Provider Details

I. General information

NPI: 1285968818
Provider Name (Legal Business Name): EASTER SEALS UCP NORTH CAROLINA & VIRGIINIA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2009
Last Update Date: 01/18/2023
Certification Date: 01/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 E MAIN ST
SALEM VA
24153-3893
US

IV. Provider business mailing address

5171 GLENWOOD AVE STE 211
RALEIGH NC
27612-3266
US

V. Phone/Fax

Practice location:
  • Phone: 540-777-7325
  • Fax: 540-777-2194
Mailing address:
  • Phone: 919-783-8898
  • Fax: 919-782-5486

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: BRETT BEAVERS
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 919-210-7661