MEDICARE: OCTOBER ROAD 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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1669763165
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OCTOBER ROAD INC.

Provider Business Mailing Address
First Line	:	119 TUNNEL RD STE D
Second Line	:
City	:	ASHEVILLE
State	:	NC
Zip	:	28805-1800
Country	:	US
Telephone Number	:	828-350-1000
Fax Number	:	828-350-1300

Provider Business Practice Location Address
First Line	:	5 OAK BRANCH DR STE E
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27407-2157
Country	:	US
Telephone Number	:	336-398-1392
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	JASON HENDRICKS
Credential	:
Telephone Number	:	814-940-0407

Provider Enumeration Date	:	05/02/2011
Last Update Date	:	04/10/2024

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