MEDICARE: THE HIAWATHA CENTER, INC.

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	261QF0400X	Federally Qualified Health Center (FQHC)
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner
3	101Y00000X	Counselor
4	101YA0400X	Addiction (Substance Use Disorder) Counselor
5	1041C0700X	Clinical Social Worker
6	106H00000X	Marriage & Family Therapist
7	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1407406713
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE HIAWATHA CENTER, INC.

Provider Business Mailing Address
First Line	:	819 W RALEIGH BLVD
Second Line	:
City	:	ROCKY MOUNT
State	:	NC
Zip	:	27803-2764
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	819 W RALEIGH BLVD
Second Line	:
City	:	ROCKY MOUNT
State	:	NC
Zip	:	27803-2764
Country	:	US
Telephone Number	:	919-345-0261
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DARIUS SMITH
Credential	:
Telephone Number	:	919-345-0261

Provider Enumeration Date	:	09/18/2019
Last Update Date	:	09/18/2019

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