Provider Demographics
NPI:1083807325
Name:ADOLESCENT CARE CENTER
Entity Type:Organization
Organization Name:ADOLESCENT CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SYLIVA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOONE
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:252-357-1226
Mailing Address - Street 1:88 US HIGHWAY 158 W
Mailing Address - Street 2:
Mailing Address - City:GATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27938-9438
Mailing Address - Country:US
Mailing Address - Phone:252-357-1244
Mailing Address - Fax:252-357-1690
Practice Address - Street 1:88 US HIGHWAY 158 W
Practice Address - Street 2:
Practice Address - City:GATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:27938-9438
Practice Address - Country:US
Practice Address - Phone:252-357-1244
Practice Address - Fax:252-357-1690
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GATES COUNTY MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC261QS1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8701702Medicaid