1891865218 NPI number — CHRYSALIS CENTER FOR COUNSELING AND EATING DISORDER TREATMENT PLLC

Table of content: (NPI 1891865218)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891865218 NPI number — CHRYSALIS CENTER FOR COUNSELING AND EATING DISORDER TREATMENT PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHRYSALIS CENTER FOR COUNSELING AND EATING DISORDER TREATMENT 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:
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:
1891865218
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/18/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3240 BURNT MILL DR STE 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILMINGTON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28403-2576
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-790-9500
Provider Business Mailing Address Fax Number:
910-796-8111

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3904 OLEANDER DR
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
WILMINGTON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28403-6717
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-790-9500
Provider Business Practice Location Address Fax Number:
910-796-8111
Provider Enumeration Date:
11/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HUNTER
Authorized Official First Name:
ALEXIS
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF PROFESSIONAL RELATIONS
Authorized Official Telephone Number:
910-790-9500

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  2805 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103TC1900X , with the licence number: LPC6828 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: C006434 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 133V00000X , with the licence number: L003399 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 355080 . This is a "MHN/TRICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 018AM . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com