1013101781 NPI number — BLACK RIVER HEALTH SERVICES, INC.

Table of content: (NPI 1013101781)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013101781 NPI number — BLACK RIVER HEALTH SERVICES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLACK RIVER 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:
6
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:
1013101781
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
301 S CAMPBELL ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BURGAW
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28425-5011
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-259-6973
Provider Business Mailing Address Fax Number:
910-259-6975

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7910 US HIGHWAY 117 S
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
ROCKY POINT
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28457-7409
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-675-0120
Provider Business Practice Location Address Fax Number:
910-675-2308
Provider Enumeration Date:
09/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MARTIN
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
SCOTT
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
910-259-6973

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , 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: 5908417 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 020A0 . This is a "BCBS NC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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