Provider Demographics
NPI:1013210129
Name:KTV ALIVE
Entity Type:Organization
Organization Name:KTV ALIVE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PHAEDRA
Authorized Official - Middle Name:N
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-774-1135
Mailing Address - Street 1:PO BOX 3284
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27331-2384
Mailing Address - Country:US
Mailing Address - Phone:919-772-1135
Mailing Address - Fax:
Practice Address - Street 1:1665 LOWER MONCURE ROAD
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:NC
Practice Address - Zip Code:27330-6403
Practice Address - Country:US
Practice Address - Phone:919-774-1135
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-10
Last Update Date:2010-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
No251B00000XAgenciesCase Management