1205988276 NPI number — PORT HUMAN SERVICES

Table of content: (NPI 1205988276)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205988276 NPI number — PORT HUMAN SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PORT HUMAN SERVICES
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:
1205988276
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2245 STANTONSBURG RD
Provider Second Line Business Mailing Address:
SUITE P
Provider Business Mailing Address City Name:
GREENVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27834-2868
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
252-752-0483
Provider Business Mailing Address Fax Number:
252-752-2971

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
227 KINGOLD ROAD
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
SNOW HILL
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28580-1303
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-233-2383
Provider Business Practice Location Address Fax Number:
252-233-2381
Provider Enumeration Date:
01/18/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SAVIDGE
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
O
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
252-752-0483

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: 8301624 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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