Provider Demographics
NPI:1003088451
Name:COMMUNITY INNOVATIONS, INC
Entity Type:Organization
Organization Name:COMMUNITY INNOVATIONS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER ENROLLMENT SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:TALESHA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROLLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-256-0824
Mailing Address - Street 1:3210 FAIRHILL DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-3215
Mailing Address - Country:US
Mailing Address - Phone:919-256-0824
Mailing Address - Fax:919-256-0833
Practice Address - Street 1:801 WILSON ST
Practice Address - Street 2:
Practice Address - City:WHITEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28472-4713
Practice Address - Country:US
Practice Address - Phone:910-642-5697
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMUNITY INNOVATIONS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-26
Last Update Date:2008-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101YP2500X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC232124Medicare PIN