Provider Demographics
NPI:1619157153
Name:NORTH CAROLINA CHILDREN'S PLACE, INC
Entity Type:Organization
Organization Name:NORTH CAROLINA CHILDREN'S PLACE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:Y
Authorized Official - Last Name:CLODFELTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-449-9775
Mailing Address - Street 1:603 GREYROCK RD
Mailing Address - Street 2:
Mailing Address - City:WHITSETT
Mailing Address - State:NC
Mailing Address - Zip Code:27377-9225
Mailing Address - Country:US
Mailing Address - Phone:336-449-9775
Mailing Address - Fax:
Practice Address - Street 1:504 SUNNYBROOK DR
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28110-2719
Practice Address - Country:US
Practice Address - Phone:336-449-9775
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-13
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-090-135322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6603342Medicaid