Provider Demographics
NPI:1679768303
Name:CHILDREN'S HEALTH OF CAROLINA DBA PEMBROKE PEDIATRICS MENTAL HEALTH
Entity Type:Organization
Organization Name:CHILDREN'S HEALTH OF CAROLINA DBA PEMBROKE PEDIATRICS MENTAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COMPLIANCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:
Authorized Official - Last Name:DUCKWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-738-8060
Mailing Address - Street 1:812 CANDY PARK RD
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE
Mailing Address - State:NC
Mailing Address - Zip Code:28372-9129
Mailing Address - Country:US
Mailing Address - Phone:910-521-0201
Mailing Address - Fax:910-521-0773
Practice Address - Street 1:400 LIBERTY HILL RD
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-2446
Practice Address - Country:US
Practice Address - Phone:910-738-8060
Practice Address - Fax:910-671-3600
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHILDREN'S HEALTH OF CAROLINA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-09-06
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890253UMedicaid