Provider Demographics
NPI:1396029740
Name:EASTER SEALS UCP NORTH CAROLINA & VIRGINIA, INC.
Entity Type:Organization
Organization Name:EASTER SEALS UCP NORTH CAROLINA & VIRGINIA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:NASHEBA
Authorized Official - Middle Name:
Authorized Official - Last Name:KEY-ALLRED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-865-8632
Mailing Address - Street 1:5171 GLENWOOD AVE
Mailing Address - Street 2:SUITE 211
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-3266
Mailing Address - Country:US
Mailing Address - Phone:919-783-8898
Mailing Address - Fax:
Practice Address - Street 1:308 BRAGG ST NE
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-3202
Practice Address - Country:US
Practice Address - Phone:252-243-3022
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-04
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X, 311Z00000X
NCMHL-098-169311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No251S00000XAgenciesCommunity/Behavioral Health
No311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility