Provider Demographics
NPI:1346519014
Name:ONE LOVE PERIODIC SERVICES, INC
Entity Type:Organization
Organization Name:ONE LOVE PERIODIC SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:STEVIE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:WIDEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-433-4567
Mailing Address - Street 1:100 QUEEN ST
Mailing Address - Street 2:
Mailing Address - City:MORGANTON
Mailing Address - State:NC
Mailing Address - Zip Code:28655-3440
Mailing Address - Country:US
Mailing Address - Phone:828-433-4567
Mailing Address - Fax:828-433-4576
Practice Address - Street 1:451 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:NC
Practice Address - Zip Code:28752-3304
Practice Address - Country:US
Practice Address - Phone:828-559-0414
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-23
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8703220Medicaid
NC5916270Medicaid
NC8301457VMedicaid
NC3410218Medicaid
NC6008242Medicaid
NC8301457HMedicaid