Provider Demographics
NPI:1770637407
Name:EASTER SEALS UCP NC & VA, INC.
Entity Type:Organization
Organization Name:EASTER SEALS UCP NC & VA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:
Authorized Official - Last Name:BEAVERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-783-8898
Mailing Address - Street 1:5171 GLENWOOD AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-3266
Mailing Address - Country:US
Mailing Address - Phone:919-783-8898
Mailing Address - Fax:919-782-5486
Practice Address - Street 1:600 LYNNDALE CT
Practice Address - Street 2:SUITE F
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858-5443
Practice Address - Country:US
Practice Address - Phone:252-353-7923
Practice Address - Fax:252-353-8001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8300473GMedicaid
NC8300473BMedicaid
NC8300473HMedicaid