Provider Demographics
NPI:1376692509
Name:CENTRAL CARE DIVISION, LLC
Entity Type:Organization
Organization Name:CENTRAL CARE DIVISION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:F
Authorized Official - Last Name:STAPLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-635-2000
Mailing Address - Street 1:405 N. BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:EDEN
Mailing Address - State:NC
Mailing Address - Zip Code:27288-5647
Mailing Address - Country:US
Mailing Address - Phone:336-635-2000
Mailing Address - Fax:336-635-2003
Practice Address - Street 1:722 MILES STREET
Practice Address - Street 2:
Practice Address - City:EDEN
Practice Address - State:NC
Practice Address - Zip Code:27288-2822
Practice Address - Country:US
Practice Address - Phone:336-635-2000
Practice Address - Fax:336-635-2003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2010-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
320900000X
NCMHL-079-080320900000X
NCMHL-079-083320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3418285Medicaid
NC6603985Medicaid
NC6603595Medicaid
NC8301618Medicaid
NC8301618BMedicaid