Provider Demographics
NPI:1326289943
Name:HIGHLAND CLINIC
Entity Type:Organization
Organization Name:HIGHLAND CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CALVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-678-2088
Mailing Address - Street 1:823 ELM ST STE 207
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28303-4164
Mailing Address - Country:US
Mailing Address - Phone:910-678-2088
Mailing Address - Fax:910-678-0915
Practice Address - Street 1:823 ELM ST STE 207
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-4164
Practice Address - Country:US
Practice Address - Phone:910-678-2088
Practice Address - Fax:910-678-0915
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-11
Last Update Date:2009-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC34418101YM0800X, 305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes305S00000XManaged Care OrganizationsPoint of Service
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8961588Medicaid
NC2234090Medicare PIN
F45205Medicare UPIN