MEDICARE: FAMILY PRESERVATION SERVICES OF NC INC - VANCE HENDERSON MIDDLE

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	:	1871937409
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY PRESERVATION SERVICES OF NC INC - VANCE HENDERSON MIDDLE

Provider Business Mailing Address
First Line	:	PO BOX 759194
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21275-9194
Country	:	US
Telephone Number	:	704-344-0491
Fax Number	:	704-344-0493

Provider Business Practice Location Address
First Line	:	219 CHARLES ST
Second Line	:
City	:	HENDERSON
State	:	NC
Zip	:	27536-4327
Country	:	US
Telephone Number	:	252-492-0054
Fax Number	:	252-430-8588

Authorized Official
Title or Position	:	NC STATE QI & TRAINING DIRECTOR
Name	:	MIRANDA LITTLE
Credential	:
Telephone Number	:	704-344-0491

Provider Enumeration Date	:	04/25/2013
Last Update Date	:	09/26/2013

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