Provider Demographics
NPI:1346505617
Name:INNERVISION INC.
Entity Type:Organization
Organization Name:INNERVISION INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:AGNES
Authorized Official - Last Name:NICHOLAS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:704-377-5047
Mailing Address - Street 1:PO BOX 31083
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28231-1083
Mailing Address - Country:US
Mailing Address - Phone:704-377-5047
Mailing Address - Fax:704-377-5043
Practice Address - Street 1:1000 BAXTER ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2859
Practice Address - Country:US
Practice Address - Phone:704-377-5047
Practice Address - Fax:704-377-5043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-11
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL 060 1242251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8300613Medicaid