1477006021 NPI number — OCEANSIDE FAMILY COUNSELING AND RESOURCE CENTER, PLLC

Table of content: (NPI 1477006021)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477006021 NPI number — OCEANSIDE FAMILY COUNSELING AND RESOURCE CENTER, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OCEANSIDE FAMILY COUNSELING AND RESOURCE CENTER, PLLC
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:
1477006021
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/02/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
710 SUNSET BLVD N STE D
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUNSET BEACH
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28468-4340
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-575-4200
Provider Business Mailing Address Fax Number:
910-575-4201

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
104 SUMMER LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WHITEVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28472-8757
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-234-2824
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/01/2016

Additional Information

Authorized Official

Authorized Official Last Name:
BROWN-JOHNSON
Authorized Official First Name:
DEANNA
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
DIRECTOR, OWNER
Authorized Official Telephone Number:
910-234-2824

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  20495 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X , with the licence number: A11182 , 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: 1730585282 . This is a "NPI" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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