Provider Demographics
NPI:1558483966
Name:INNERVISION, INC.
Entity Type:Organization
Organization Name:INNERVISION, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:NICHOLAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-377-5047
Mailing Address - Street 1:PO BOX 31083
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28231-1083
Mailing Address - Country:US
Mailing Address - Phone:704-377-5047
Mailing Address - Fax:
Practice Address - Street 1:400 E TRADE ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28202-2428
Practice Address - Country:US
Practice Address - Phone:704-377-5047
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-05
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL 060 003251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8300613Medicaid