Provider Demographics
NPI:1114058104
Name:DIVERSIFIED CHOICE
Entity Type:Organization
Organization Name:DIVERSIFIED CHOICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:A
Authorized Official - Last Name:BARBOUR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-926-9032
Mailing Address - Street 1:5032 HUTCHINS ST
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-2353
Mailing Address - Country:US
Mailing Address - Phone:336-923-2817
Mailing Address - Fax:
Practice Address - Street 1:5032 HUTCHINS ST
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-2353
Practice Address - Country:US
Practice Address - Phone:336-923-2817
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3409483Medicaid