Provider Demographics
NPI:1629118013
Name:WATERS' PROVIDER CARE SERVICES, INC.
Entity Type:Organization
Organization Name:WATERS' PROVIDER CARE SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY - TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ERIC
Authorized Official - Last Name:WATERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-566-3600
Mailing Address - Street 1:104 W JAMES ST
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:NC
Mailing Address - Zip Code:28551-1727
Mailing Address - Country:US
Mailing Address - Phone:252-566-3600
Mailing Address - Fax:
Practice Address - Street 1:104 W JAMES ST
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:NC
Practice Address - Zip Code:28551-1727
Practice Address - Country:US
Practice Address - Phone:252-566-3600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-054-124320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities