Provider Demographics
NPI:1396220638
Name:1 FOUNDATION
Entity Type:Organization
Organization Name:1 FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ELIJAH
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMPTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-946-0995
Mailing Address - Street 1:9904 BONITA LN APT 411
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-1078
Mailing Address - Country:US
Mailing Address - Phone:773-946-0995
Mailing Address - Fax:
Practice Address - Street 1:150 BW THOMAS DR
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29708-7230
Practice Address - Country:US
Practice Address - Phone:773-946-0995
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-02
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC=========Medicaid