Provider Demographics
NPI:1710687967
Name:CAROLINA OUTREACH, LLC
Entity Type:Organization
Organization Name:CAROLINA OUTREACH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:MITCHELL
Authorized Official - Last Name:VEDDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-844-1007
Mailing Address - Street 1:2670 DURHAM CHAPEL HILL BLVD
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-2829
Mailing Address - Country:US
Mailing Address - Phone:720-402-2296
Mailing Address - Fax:
Practice Address - Street 1:2508 APRIL LIU LN APT 311
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28213-6966
Practice Address - Country:US
Practice Address - Phone:704-332-8787
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CAROLINA OUTREACH, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-03-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC08300219Medicaid