Provider Demographics
NPI:1598939969
Name:SPECTRUM SUPPORT SERVICES
Entity Type:Organization
Organization Name:SPECTRUM SUPPORT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:ILEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HILL
Authorized Official - Suffix:
Authorized Official - Credentials:MED
Authorized Official - Phone:919-954-1171
Mailing Address - Street 1:6108 BIG SANDY DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-5790
Mailing Address - Country:US
Mailing Address - Phone:919-954-1171
Mailing Address - Fax:919-874-0812
Practice Address - Street 1:6108 BIG SANDY DR
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27616-5790
Practice Address - Country:US
Practice Address - Phone:919-954-1171
Practice Address - Fax:919-874-0812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-16
Last Update Date:2008-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8302146Medicaid