Provider Demographics
NPI:1598908519
Name:ULTIMATE BEHAVIORAL HEALTH CARE SERVICES
Entity Type:Organization
Organization Name:ULTIMATE BEHAVIORAL HEALTH CARE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:D
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-349-1025
Mailing Address - Street 1:2817 COLE RIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27107-2667
Mailing Address - Country:US
Mailing Address - Phone:252-349-1025
Mailing Address - Fax:
Practice Address - Street 1:2817 COLE RIDGE CIR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27107-2667
Practice Address - Country:US
Practice Address - Phone:252-349-1025
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-07
Last Update Date:2009-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health