Provider Demographics
NPI:1174511976
Name:BLACK RIVER HEALTH SERVICES INC
Entity Type:Organization
Organization Name:BLACK RIVER HEALTH SERVICES INC
Other - Org Name:BLACK RIVER HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LEE ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:AMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-259-6973
Mailing Address - Street 1:301 S CAMPBELL ST
Mailing Address - Street 2:
Mailing Address - City:BURGAW
Mailing Address - State:NC
Mailing Address - Zip Code:28425-5011
Mailing Address - Country:US
Mailing Address - Phone:910-259-6973
Mailing Address - Fax:910-259-6975
Practice Address - Street 1:109 W CHURCH ST
Practice Address - Street 2:
Practice Address - City:ATKINSON
Practice Address - State:NC
Practice Address - Zip Code:28421-9230
Practice Address - Country:US
Practice Address - Phone:910-283-7783
Practice Address - Fax:910-283-7927
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-06
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC343867ACMedicaid
03009OtherBCBS
NC343867Medicare Oscar/Certification