MEDICARE: EASTER SEALS UCP NORTH CAROLINA & VIRGINIA

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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1295169720
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EASTER SEALS UCP NORTH CAROLINA & VIRGINIA

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	:	511 WILSON AVE
Second Line	:
City	:	SPRING LAKE
State	:	NC
Zip	:	28390-3648
Country	:	US
Telephone Number	:	919-783-8898
Fax Number	:

Authorized Official
Title or Position	:	VP SERVICE LINE
Name	:	RICHARD EDWARDS
Credential	:
Telephone Number	:	919-783-8898

Provider Enumeration Date	:	09/03/2013
Last Update Date	:	09/03/2013

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