1427159078 NPI number — BRITE SMILZ FAMILY & COMMUNITY CONNECTIONS LLC

Table of content: (NPI 1427159078)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427159078 NPI number — BRITE SMILZ FAMILY & COMMUNITY CONNECTIONS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRITE SMILZ FAMILY & COMMUNITY CONNECTIONS 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:
Provider Other Organization Name Type Code:
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:
1427159078
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 86
Provider Second Line Business Mailing Address:
1165 GREGORY DR
Provider Business Mailing Address City Name:
ROANOKE RAPIDS
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27870
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
252-537-7575
Provider Business Mailing Address Fax Number:
252-537-9008

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1165 GREGORY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROANOKE RAPIDS
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27870
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-537-7575
Provider Business Practice Location Address Fax Number:
252-537-9008
Provider Enumeration Date:
09/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DAWSON
Authorized Official First Name:
EVELYN
Authorized Official Middle Name:
S
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
252-537-7575

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 101YA0400X , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 103T00000X , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 1041C0700X , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 106H00000X , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 171M00000X , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 018G5 . This is a "BLUECROSS BLUESHIELD" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 6005333 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8301698Q , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8300814B , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8300814G , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8301698P , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8300599B , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3408200 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8300599G , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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