Provider Demographics
NPI:1679682421
Name:PHP OF NC, INC
Entity Type:Organization
Organization Name:PHP OF NC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JUSTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:WIGGINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-220-0021
Mailing Address - Street 1:PO BOX 20014
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-0027
Mailing Address - Country:US
Mailing Address - Phone:919-220-0021
Mailing Address - Fax:919-220-4555
Practice Address - Street 1:4125 BEN FRANKLIN BLVD
Practice Address - Street 2:SUITE 180
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-2167
Practice Address - Country:US
Practice Address - Phone:919-220-0021
Practice Address - Fax:919-220-4555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-032-255251C00000X, 253Z00000X
NCHC1631251E00000X
NCMHL-0320255251S00000X
NCMHL-032-149320600000X
NCMHL-032-245320600000X
NCMHL-032-133320600000X
NCMHL-032-349320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No251E00000XAgenciesHome Health
No251S00000XAgenciesCommunity/Behavioral Health
No253Z00000XAgenciesIn Home Supportive Care
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3408783Medicaid
NC6600586Medicaid