Provider Demographics
NPI:1760528772
Name:AMW FOUNDATION
Entity Type:Organization
Organization Name:AMW FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:CHET
Authorized Official - Middle Name:
Authorized Official - Last Name:WEST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-899-6740
Mailing Address - Street 1:3209 GRESHAM LAKE RD
Mailing Address - Street 2:113
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-3757
Mailing Address - Country:US
Mailing Address - Phone:919-850-2155
Mailing Address - Fax:919-850-2353
Practice Address - Street 1:3209 GRESHAM LAKE RD
Practice Address - Street 2:113
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-4151
Practice Address - Country:US
Practice Address - Phone:919-850-2155
Practice Address - Fax:919-850-2353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6005692Medicaid