1063554004 NPI number — ROBESON HEALTH CARE CORPORATION

Table of content: (NPI 1063554004)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063554004 NPI number — ROBESON HEALTH CARE CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROBESON HEALTH CARE CORPORATION
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:
1063554004
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/28/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
60 COMMERCE PLAZA CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEMBROKE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28372-7386
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-521-2900
Provider Business Mailing Address Fax Number:
910-775-9165

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
309 EAST WARDELL DRIVE
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
PEMBROKE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28372-7998
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-521-1464
Provider Business Practice Location Address Fax Number:
910-521-1852
Provider Enumeration Date:
02/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HALL
Authorized Official First Name:
TIM
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF BEHAVIORAL HEALTH SVCS
Authorized Official Telephone Number:
910-521-2900

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  MHL-078-062 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X , with the licence number: MHL-078-062 , 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: 6005789 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8300812B , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8300812 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8300812G , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8300812P , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8300812Q , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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