Provider Demographics
NPI:1194861617
Name:J IVERSON RIDDLE DEVELOPMENTAL CENTER
Entity Type:Organization
Organization Name:J IVERSON RIDDLE DEVELOPMENTAL CENTER
Other - Org Name:WESTERN CAROLINA CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:DIVISION DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:BURKES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-855-4700
Mailing Address - Street 1:300 ENOLA ROAD
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:NC
Mailing Address - Zip Code:28655-4608
Mailing Address - Country:US
Mailing Address - Phone:828-433-2722
Mailing Address - Fax:828-433-2724
Practice Address - Street 1:300 ENOLA ROAD
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:NC
Practice Address - Zip Code:28655-4608
Practice Address - Country:US
Practice Address - Phone:828-433-2722
Practice Address - Fax:828-433-2724
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3406014Medicaid