Provider Demographics
NPI:1477784627
Name:CLUB NOVA COMMUNITY INC
Entity Type:Organization
Organization Name:CLUB NOVA COMMUNITY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:KINKAID
Authorized Official - Last Name:DUNN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-968-6682
Mailing Address - Street 1:PO BOX 1346
Mailing Address - Street 2:
Mailing Address - City:CARRBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27510-3346
Mailing Address - Country:US
Mailing Address - Phone:919-968-6682
Mailing Address - Fax:919-968-2522
Practice Address - Street 1:103 W MAIN ST STE D
Practice Address - Street 2:
Practice Address - City:CARRBORO
Practice Address - State:NC
Practice Address - Zip Code:27510-1691
Practice Address - Country:US
Practice Address - Phone:919-968-6682
Practice Address - Fax:919-968-2522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-06
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0058101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8301156-SMedicaid
NC8301156-BMedicaid