1861780322 NPI number — WICKER STREET GROUP HOME

Table of content: (NPI 1861780322)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861780322 NPI number — WICKER STREET GROUP HOME

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WICKER STREET GROUP HOME
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:
1861780322
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/12/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 981
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAW RIVER
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27258-0981
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-578-0004
Provider Business Mailing Address Fax Number:
336-227-4350

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1620 FLORA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BURLINGTON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27217-1018
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-227-4350
Provider Business Practice Location Address Fax Number:
336-227-4350
Provider Enumeration Date:
07/19/2011

Additional Information

Authorized Official

Authorized Official Last Name:
ROGERS
Authorized Official First Name:
DOROTHEA
Authorized Official Middle Name:
VIVIAN
Authorized Official Title or Position:
DIRECTOR/OWNER
Authorized Official Telephone Number:
336-578-0004

Provider Taxonomy Codes

  • Taxonomy code: 3104A0625X , with the licence number:  001-217 , 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)





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