MEDICARE: INTEGRATED CARE SUPPORT SVCS NC

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	251B00000X	Case Management Agency

General Provider Information

NPI Number	:	1306781158
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTEGRATED CARE SUPPORT SVCS NC

Provider Business Mailing Address
First Line	:	96031 BROADMOOR RD
Second Line	:
City	:	FERNANDINA BEACH
State	:	FL
Zip	:	32034
Country	:	US
Telephone Number	:	704-929-8119
Fax Number	:

Provider Business Practice Location Address
First Line	:	96031 BROADMOOR RD
Second Line	:
City	:	FERNANDINA BEACH
State	:	FL
Zip	:	32034
Country	:	US
Telephone Number	:	704-929-8119
Fax Number	:

Authorized Official
Title or Position	:	QUALIFIED PROFESSIONAL/CASE MANAGER
Name	:	KRISTY PAVELOCK
Credential	:	B.A.
Telephone Number	:	704-929-8119

Provider Enumeration Date	:	04/20/2026
Last Update Date	:	04/20/2026

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