1396087391 NPI number — NC DEPARTMENT OF MILITARY AND VETERANS AFFAIRS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396087391 NPI number — NC DEPARTMENT OF MILITARY AND VETERANS AFFAIRS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NC DEPARTMENT OF MILITARY AND VETERANS AFFAIRS
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:
1396087391
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/22/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4001 MAIL SERVICE CTR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RALEIGH
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27699-4001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
984-204-2982
Provider Business Mailing Address Fax Number:
984-204-8344

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2150 HULL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KINSTON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28504-2052
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-939-8000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/18/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HOLLEY
Authorized Official First Name:
LYNETHIA
Authorized Official Middle Name:
N
Authorized Official Title or Position:
PROVIDER ENROLLMENT SPECIALIST
Authorized Official Telephone Number:
770-806-6875

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  NC0634 , 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: NH0634 . This is a "STATE OF NORTH CAROLINA LICENSURE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".