Provider Demographics
NPI:1043365869
Name:PRIDE IN NORTH CAROLINA, LLC
Entity Type:Organization
Organization Name:PRIDE IN NORTH CAROLINA, LLC
Other - Org Name:PRIDE IN NORTH CAROLINA, INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DIRECTOR OF BUSINESS OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:RUTSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-452-1460
Mailing Address - Street 1:231 COMMERCE ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27858-5029
Mailing Address - Country:US
Mailing Address - Phone:252-321-8080
Mailing Address - Fax:252-321-7999
Practice Address - Street 1:2416 BEDGOOD DRIVE
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-8515
Practice Address - Country:US
Practice Address - Phone:252-265-9200
Practice Address - Fax:252-237-8600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2017-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8300246Medicaid
NC8300246GMedicaid
NC8300246BMedicaid