Provider Demographics
NPI:1417045741
Name:EXCHANGE CLUB CHILD ABUSE PREVENTION CENTER OF NORTH CAROLINA
Entity Type:Organization
Organization Name:EXCHANGE CLUB CHILD ABUSE PREVENTION CENTER OF NORTH CAROLINA
Other - Org Name:EXCHANGE SCAN
Other - Org Type:Other Name
Authorized Official - Title/Position:OPERATIONS MANAGER/COMPTROLLER
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:BRODEUR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-748-9028
Mailing Address - Street 1:500 W NORTHWEST BLVD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27105-6526
Mailing Address - Country:US
Mailing Address - Phone:336-748-9028
Mailing Address - Fax:336-748-9030
Practice Address - Street 1:500 W NORTHWEST BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27105-6526
Practice Address - Country:US
Practice Address - Phone:336-748-9028
Practice Address - Fax:336-748-9030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6005439Medicaid