MEDICARE: EASTER SEALS UCP NORTH CAROLINA & VIRGINIA INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3104A0625X	Assisted Living Facility (Mental Illness)

General Provider Information

NPI Number	:	1073934162
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EASTER SEALS UCP NORTH CAROLINA & VIRGINIA INC.

Provider Business Mailing Address
First Line	:	5171 GLENWOOD AVE
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27612-3266
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1015 ELIZABETH DR
Second Line	:
City	:	DALLAS
State	:	NC
Zip	:	28034-7751
Country	:	US
Telephone Number	:	919-789-8898
Fax Number	:

Authorized Official
Title or Position	:	VP
Name	:	RICHARD EDWARDS
Credential	:
Telephone Number	:	919-789-8898

Provider Enumeration Date	:	12/17/2013
Last Update Date	:	12/17/2013

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