1700093184 NPI number — COMMUNITY INNOVATIONS, INC.

Table of content: (NPI 1700093184)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700093184 NPI number — COMMUNITY INNOVATIONS, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMMUNITY INNOVATIONS, 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:
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:
1700093184
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/16/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3210 FAIRHILL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RALEIGH
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27612-3215
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-256-0824
Provider Business Mailing Address Fax Number:
919-256-0833

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
118 E WALTER ST
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:
28472-4142
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-640-2724
Provider Business Practice Location Address Fax Number:
910-640-3474
Provider Enumeration Date:
05/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
JONES
Authorized Official First Name:
HAROLD
Authorized Official Middle Name:
E
Authorized Official Title or Position:
MEMBER MGR/OWNER
Authorized Official Telephone Number:
919-256-0824

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X , 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: 8300961G , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8300961 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8300961B , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8300961H , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8300961V , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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