Provider Demographics
NPI:1508996059
Name:PETERKIN & ASSOCIATES, INC.
Entity Type:Organization
Organization Name:PETERKIN & ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALICE
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:910-323-1817
Mailing Address - Street 1:131 HAY ST STE 201
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28301-5649
Mailing Address - Country:US
Mailing Address - Phone:910-323-1817
Mailing Address - Fax:
Practice Address - Street 1:114 GREENHOUSE LN
Practice Address - Street 2:
Practice Address - City:SOUTHERN PINES
Practice Address - State:NC
Practice Address - Zip Code:28387-3140
Practice Address - Country:US
Practice Address - Phone:910-323-1817
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-063-017310400000X, 310500000X, 315P00000X, 320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No310500000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Mental Illness
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC340604WMedicaid