Provider Demographics
NPI:1336506146
Name:ALBERTA PROFESSIONAL SERVICES
Entity Type:Organization
Organization Name:ALBERTA PROFESSIONAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:DEREK
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:336-273-2640
Mailing Address - Street 1:PO BOX 14884
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27415-4884
Mailing Address - Country:US
Mailing Address - Phone:336-273-2640
Mailing Address - Fax:336-273-6522
Practice Address - Street 1:3107 S ELM EUGENE ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27406-5201
Practice Address - Country:US
Practice Address - Phone:336-273-2640
Practice Address - Fax:336-273-6522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-25
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3418317Medicaid