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NPI Code Detail

MEDICARE: INTENSIVE MENTAL CARE INC

MEDICARE: INTENSIVE MENTAL CARE 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
11041C0700XClinical Social Worker
22084P0800XPsychiatry Physician
3251S00000XCommunity/Behavioral Health Agency

General Provider Information

NPI Number : 1962712653
Entity Type Code : Organization
Provider Name (Legal Business Name) : INTENSIVE MENTAL CARE INC
Provider Business Mailing Address
First Line : PO BOX 1207
Second Line :
City : WAKE FOREST
State : NC
Zip : 27588-1207
Country : US
Telephone Number : 252-312-8207
Fax Number : 888-535-2496
Provider Business Practice Location Address
First Line : 2015 AYRSLEY TOWN BLVD STE 202
Second Line :
City : CHARLOTTE
State : NC
Zip : 28273-4068
Country : US
Telephone Number : 252-312-8207
Fax Number : 888-535-2496
Authorized Official
Title or Position : PRESIDENT
Name : EULANDA ELLIOTT
Credential :
Telephone Number : 252-312-8207
Provider Enumeration Date : 10/14/2010
Last Update Date : 10/14/2010

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