Provider Demographics
NPI:1043459852
Name:NOVA-IC, INC.
Entity Type:Organization
Organization Name:NOVA-IC, INC.
Other - Org Name:HOLLY STREET HOME
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:PRIDGEN
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:919-734-8803
Mailing Address - Street 1:PO BOX 11077
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27532-1077
Mailing Address - Country:US
Mailing Address - Phone:919-734-8803
Mailing Address - Fax:919-735-6825
Practice Address - Street 1:1509 HOLLY STREET
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27534-3033
Practice Address - Country:US
Practice Address - Phone:919-735-4736
Practice Address - Fax:919-735-6825
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-18
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-096-114315P00000X, 315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3406312Medicaid