1720285562 NPI number — THE JOHN OLIVER CENTER #3

Table of content: (NPI 1720285562)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720285562 NPI number — THE JOHN OLIVER CENTER #3

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE JOHN OLIVER CENTER #3
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:
1720285562
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 1504
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GOLDSBORO
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27533-1504
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-739-5859
Provider Business Mailing Address Fax Number:
919-735-9745

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
535 BROGDEN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DUDLEY
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28333-8187
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-736-2135
Provider Business Practice Location Address Fax Number:
919-735-9745
Provider Enumeration Date:
06/27/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
OLIVER
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
919-739-5859

Provider Taxonomy Codes

  • Taxonomy code: 322D00000X , with the licence number:  MHL096140 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 6603798 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".