Provider Demographics
NPI:1043336985
Name:COMMUNITY CARE CENTER IND
Entity Type:Organization
Organization Name:COMMUNITY CARE CENTER IND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ESAU
Authorized Official - Middle Name:ARNOLD
Authorized Official - Last Name:MCMORRIS
Authorized Official - Suffix:
Authorized Official - Credentials:QMHP
Authorized Official - Phone:252-208-1928
Mailing Address - Street 1:110 S QUEEN ST
Mailing Address - Street 2:SUITE 118
Mailing Address - City:KINSTON
Mailing Address - State:NC
Mailing Address - Zip Code:28501-4973
Mailing Address - Country:US
Mailing Address - Phone:252-208-1928
Mailing Address - Fax:252-559-2055
Practice Address - Street 1:110 S QUEEN ST
Practice Address - Street 2:SUITE 118
Practice Address - City:KINSTON
Practice Address - State:NC
Practice Address - Zip Code:28501-4973
Practice Address - Country:US
Practice Address - Phone:252-208-1928
Practice Address - Fax:252-559-2055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC251S00000X251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8301433Medicaid