Provider Demographics
NPI:1609995380
Name:SUCCESS FOR LIVING SUPPORT SERVICES,
Entity Type:Organization
Organization Name:SUCCESS FOR LIVING SUPPORT SERVICES,
Other - Org Name:SUCCESS FOR LIVING SUPPORT SERVICES
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ADMINISTRATOR/CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELAINE
Authorized Official - Middle Name:B
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-243-3290
Mailing Address - Street 1:PO BOX 1351
Mailing Address - Street 2:
Mailing Address - City:ZEBULON
Mailing Address - State:NC
Mailing Address - Zip Code:27589-1351
Mailing Address - Country:US
Mailing Address - Phone:252-243-3290
Mailing Address - Fax:252-243-3290
Practice Address - Street 1:806 S TARBORO ST
Practice Address - Street 2:SUITE B-19
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-3880
Practice Address - Country:US
Practice Address - Phone:252-243-3290
Practice Address - Fax:252-243-3290
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2009-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC2399251J00000X, 3747P1801X
251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Multi-Specialty
No251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6601025Medicaid
NC6601760Medicaid
NC3409617Medicaid