Provider Demographics
NPI:1215216700
Name:COMMUNITY OUTREACH ENRICHMENT CENTER INC.
Entity Type:Organization
Organization Name:COMMUNITY OUTREACH ENRICHMENT CENTER INC.
Other - Org Name:HOLLY'S COMMUNITY OUTREACH CARE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ADMINISTATOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:ANNETTE
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-824-2595
Mailing Address - Street 1:PO BOX 1153
Mailing Address - Street 2:329 BRADY STREET EXT.
Mailing Address - City:RAMSEUR
Mailing Address - State:NC
Mailing Address - Zip Code:27316
Mailing Address - Country:US
Mailing Address - Phone:336-824-2595
Mailing Address - Fax:
Practice Address - Street 1:329 BRADY STREET EXT
Practice Address - Street 2:
Practice Address - City:RAMSEUR
Practice Address - State:NC
Practice Address - Zip Code:27316-8703
Practice Address - Country:US
Practice Address - Phone:336-824-2595
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-15
Last Update Date:2013-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC76000398251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7200564Medicaid