Provider Demographics
NPI:1689014748
Name:BRUNSWICK COMMUNITY COLLEGE INTERAGENCY PROGRAM
Entity Type:Organization
Organization Name:BRUNSWICK COMMUNITY COLLEGE INTERAGENCY PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:KRISTA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:ENGELS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-755-7394
Mailing Address - Street 1:50 COLLEGE RD NE
Mailing Address - Street 2:
Mailing Address - City:BOLIVIA
Mailing Address - State:NC
Mailing Address - Zip Code:28422-9021
Mailing Address - Country:US
Mailing Address - Phone:910-755-7394
Mailing Address - Fax:910-755-7493
Practice Address - Street 1:50 COLLEGE RD NE
Practice Address - Street 2:
Practice Address - City:BOLIVIA
Practice Address - State:NC
Practice Address - Zip Code:28422-9021
Practice Address - Country:US
Practice Address - Phone:910-755-7394
Practice Address - Fax:910-755-7493
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-03
Last Update Date:2013-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-010-001251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3404933Medicaid