Provider Demographics
NPI:1508291683
Name:SPIRIT OF EXCELLENCE COMMUNITY OUTREACH, INC
Entity Type:Organization
Organization Name:SPIRIT OF EXCELLENCE COMMUNITY OUTREACH, INC
Other - Org Name:GUARDIAN CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:CHANTE
Authorized Official - Middle Name:GISELLE
Authorized Official - Last Name:HINES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-265-0304
Mailing Address - Street 1:PO BOX 752
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28541-0752
Mailing Address - Country:US
Mailing Address - Phone:910-382-6595
Mailing Address - Fax:
Practice Address - Street 1:510 CRISSY DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28540-9183
Practice Address - Country:US
Practice Address - Phone:910-219-0459
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-09
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC320800000X
NCMHL-067-157320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3418119Medicaid