Provider Demographics
NPI:1326246950
Name:KIDS INTERACTIVE DEVELOPMENTAL SERVICES LLC
Entity Type:Organization
Organization Name:KIDS INTERACTIVE DEVELOPMENTAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:RAGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-224-3687
Mailing Address - Street 1:1154 BELMONT CT
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28027-8666
Mailing Address - Country:US
Mailing Address - Phone:704-224-3687
Mailing Address - Fax:704-785-8096
Practice Address - Street 1:1154 BELMONT CT
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28027-8666
Practice Address - Country:US
Practice Address - Phone:704-224-3687
Practice Address - Fax:704-785-8096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-05
Last Update Date:2009-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8301595Medicaid