1043365869 NPI number — PRIDE IN NORTH CAROLINA, LLC

Table of content: (NPI 1043365869)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043365869 NPI number — PRIDE IN NORTH CAROLINA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRIDE IN NORTH CAROLINA, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PRIDE IN NORTH CAROLINA, INC
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043365869
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/04/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
231 COMMERCE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27858-5029
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
252-321-8080
Provider Business Mailing Address Fax Number:
252-321-7999

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2416 BEDGOOD DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILSON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27893-8515
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-265-9200
Provider Business Practice Location Address Fax Number:
252-237-8600
Provider Enumeration Date:
01/24/2007

Additional Information

Authorized Official

Authorized Official Last Name:
RUTSKI
Authorized Official First Name:
JASON
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF BUSINESS OPERATIONS
Authorized Official Telephone Number:
910-452-1460

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 8300246 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8300246G , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8300246B , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com