Provider Demographics
NPI:1154473239
Name:PORT HEALTH SERVICES
Entity Type:Organization
Organization Name:PORT HEALTH SERVICES
Other - Org Name:PORT HUMAN SERVICES
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:
Authorized Official - Last Name:BEAVERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-210-7661
Mailing Address - Street 1:4300 SAPPHIRE CT STE 110
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-9079
Mailing Address - Country:US
Mailing Address - Phone:252-830-7540
Mailing Address - Fax:252-413-0932
Practice Address - Street 1:144 COMMUNITY COLLEGE RD STE C
Practice Address - Street 2:
Practice Address - City:AHOSKIE
Practice Address - State:NC
Practice Address - Zip Code:27910-8047
Practice Address - Country:US
Practice Address - Phone:252-332-5086
Practice Address - Fax:252-332-5243
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
NCMHL-046-015324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8301162Medicaid