Provider Demographics
NPI:1609182534
Name:AMW FOUNDATION
Entity Type:Organization
Organization Name:AMW FOUNDATION
Other - Org Name:AMW FOUNDATION
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:CHET
Authorized Official - Middle Name:
Authorized Official - Last Name:WEST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-850-2155
Mailing Address - Street 1:3209 GRESHAM LAKE RD
Mailing Address - Street 2:SUITE 113
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-3757
Mailing Address - Country:US
Mailing Address - Phone:919-850-2155
Mailing Address - Fax:919-850-2325
Practice Address - Street 1:907 HAY ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28305-5366
Practice Address - Country:US
Practice Address - Phone:919-802-1739
Practice Address - Fax:919-850-2325
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-30
Last Update Date:2010-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6507101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6008087Medicaid