Provider Demographics
NPI:1437448750
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:CONTRACT 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:919-783-8898
Mailing Address - Street 1:5171 GLENWOOD AVE
Mailing Address - Street 2:STE 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:919-782-5486
Practice Address - Street 1:1142 NORTH ANDY GRIFFITH PARKWAY
Practice Address - Street 2:
Practice Address - City:MOUNT AIRY
Practice Address - State:NC
Practice Address - Zip Code:27030-2954
Practice Address - Country:US
Practice Address - Phone:336-789-9492
Practice Address - Fax:336-789-9587
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-07
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No172V00000XOther Service ProvidersCommunity Health WorkerGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3408598Medicaid