PRIDE IN NORTH CAROLINA, LLC

Provider Demographics

• NPI: 1760420186
• Name: PRIDE IN NORTH CAROLINA, LLC
• Entity Type: Organization
• Organization Name: PRIDE IN NORTH CAROLINA, LLC
• Authorized Official - Title/Position: DIRECTOR OF BUSINESS OPERATIONS
• Authorized Official - Prefix: MR
• Authorized Official - First Name: JASON
• Authorized Official - Last Name: RUTSKI
• Authorized Official - Phone: 910-452-1460
• Mailing Address - Street 1: 231 COMMERCE ST
• Mailing Address - City: GREENVILLE
• Mailing Address - State: NC
• Mailing Address - Zip Code: 27858-5029
• Mailing Address - Country: US
• Mailing Address - Phone: 252-321-8080
• Mailing Address - Fax: 252-321-7999
• Practice Address - Street 1: 1400 WEST CHURCH STREET EXT.
• Practice Address - City: ELIZABETH CITY
• Practice Address - State: NC
• Practice Address - Zip Code: 27909-4510
• Practice Address - Country: US
• Practice Address - Phone: 252-331-0322
• Practice Address - Fax: 252-331-0320
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2006-06-04
• Last Update Date: 2017-10-04

Provider Licenses

State	License ID	Taxonomies
		101YM0800X, 101YP2500X, 103T00000X, 1041C0700X, 2084P0800X, 251B00000X, 251S00000X
NC		251S00000X, 261QM0850X
NC	MHL-067-186	261QM0850X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization	Group
Yes	251S00000X	Agencies	Community/Behavioral Health		Group - Multi-Specialty
No	101YM0800X	Behavioral Health & Social Service Providers	Counselor	Mental Health	Group - Multi-Specialty
No	101YP2500X	Behavioral Health & Social Service Providers	Counselor	Professional	Group - Multi-Specialty
No	103T00000X	Behavioral Health & Social Service Providers	Psychologist		Group - Multi-Specialty
No	1041C0700X	Behavioral Health & Social Service Providers	Social Worker	Clinical	Group - Multi-Specialty
No	2084P0800X	Allopathic & Osteopathic Physicians	Psychiatry & Neurology	Psychiatry	Group - Multi-Specialty
No	251B00000X	Agencies	Case Management		Group - Multi-Specialty
No	261QM0850X	Ambulatory Health Care Facilities	Clinic/Center	Adult Mental Health	Group - Multi-Specialty

Provider Identifiers

State	Identifier ID	ID Type	Issuer
NC	6005354	Medicaid
NC	8300244B	Medicaid
NC	8300247H	Medicaid
NC	8300338	Medicaid
NC	6005355	Medicaid
NC	6006644	Medicaid
NC	8300581G	Medicaid
NC	5900421	Medicaid
NC	6005302	Medicaid
NC	6006660	Medicaid
NC	8300244H	Medicaid
NC	8300246B	Medicaid
NC	8300338B	Medicaid
NC	8300246	Medicaid
NC	8300246G	Medicaid
NC	8300581	Medicaid
NC	8300581H	Medicaid
NC	8303103	Medicaid
NC	8703008	Medicaid
NC	333347	Other	HEALTH CHOICE
NC	8300245H	Medicaid
NC	225175471	Other	HUMANA GOLD CHOICE
NC	6005356	Medicaid
NC	8300244G	Medicaid
NC	8300246H	Medicaid
NC	8300247B	Medicaid
NC	8300247G	Medicaid
NC	8300338H	Medicaid
NC	8300245	Medicaid
NC	8300245B	Medicaid
NC	8300245G	Medicaid
NC	8300581B	Medicaid
NC	017E1	Other	BCBSNC
NC	3410008	Medicaid
NC	341008	Medicaid
NC	8300244	Medicaid
NC	8300247	Medicaid
NC	8300245B	Medicaid
NC	8300338	Medicaid
NC	8300338B	Medicaid
NC	8300581	Medicaid