=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558414466
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EZCARE PROVIDERS INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/22/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4202 SCOTNEY DR
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27407-7558
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-638-6634
-----------------------------------------------------
Fax | 336-638-5994
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 21743
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27420-1743
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-638-6634
-----------------------------------------------------
Fax | 336-638-5994
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MR. RICHMOND C. OKORO
-----------------------------------------------------
Credential | MS
-----------------------------------------------------
Telephone | 336-638-6634
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 322D00000X
-----------------------------------------------------
Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
-----------------------------------------------------
License Number | MHL-046-762
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------