1780693663 NPI number — PENICK VILLAGE INC

Table of content: MICHAEL LOWELL MATTHEWS LMHCA (NPI 1316427917)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780693663 NPI number — PENICK VILLAGE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PENICK VILLAGE 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:
EPISCOPAL HOME FOR THE AGEING IN THE DIOCES OF NC
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:
1780693663
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/16/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
401 E RHODE ISLAND AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHERN PINES
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28387-4009
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-692-0300
Provider Business Mailing Address Fax Number:
910-692-5509

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
401 E RHODE ISLAND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTHERN PINES
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28387-4009
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-692-0300
Provider Business Practice Location Address Fax Number:
910-692-5509
Provider Enumeration Date:
08/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MOONEY
Authorized Official First Name:
CHRISTOPHER
Authorized Official Middle Name:
Authorized Official Title or Position:
SENIOR DIRECTOR OF ACCOUNTING
Authorized Official Telephone Number:
910-692-0434

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  NH0127 , 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: 3405111 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 345111 . This is a "MEDICARE SKILLED NURSING" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 3406353 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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