1932371655 NPI number — FAMILY LEGACY MENTAL HEALTH SERVICES INC

Table of content: (NPI 1932371655)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932371655 NPI number — FAMILY LEGACY MENTAL HEALTH SERVICES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY LEGACY MENTAL HEALTH SERVICES INC
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:
1932371655
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/18/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1011 SCHAUB DR
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
RALEIGH
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27606-1862
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-834-2000
Provider Business Mailing Address Fax Number:
919-834-2001

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1007 BROAD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DURHAM
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27705-4143
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-834-2000
Provider Business Practice Location Address Fax Number:
919-834-2001
Provider Enumeration Date:
04/02/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
STACEY
Authorized Official First Name:
LISA
Authorized Official Middle Name:
DYAN
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
919-834-2000

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  6102775 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC0700X , with the licence number: 6107485 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC1900X , with the licence number: 6001168 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 106H00000X , with the licence number: 6105171 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080A0000X , with the licence number: 9300596 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251B00000X ; 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" .
  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 8302925 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8302411 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5913953 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6006506 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".