1942505987 NPI number — PHYSICIAN ALLIANCE FOR MENTAL HEALTH LLC

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 1942505987 NPI number — PHYSICIAN ALLIANCE FOR MENTAL HEALTH LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHYSICIAN ALLIANCE FOR MENTAL HEALTH 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:
1942505987
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/10/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 15511
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILMINGTON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28408-5511
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-794-3929
Provider Business Mailing Address Fax Number:
910-798-2303

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3208 OLEANDER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILMINGTON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28403-0800
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-794-3929
Provider Business Practice Location Address Fax Number:
910-798-2303
Provider Enumeration Date:
01/24/2011

Additional Information

Authorized Official

Authorized Official Last Name:
KACZYNSKI
Authorized Official First Name:
WENDY
Authorized Official Middle Name:
RENE'
Authorized Official Title or Position:
PROVIDER MANAGER
Authorized Official Telephone Number:
910-262-7107

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3410154 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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