Provider Demographics
NPI:1780004135
Name:ONE LOVE PERIODICS
Entity Type:Organization
Organization Name:ONE LOVE PERIODICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:WIDEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:QP
Authorized Official - Phone:704-640-5501
Mailing Address - Street 1:121 WORTHAM ST STE G
Mailing Address - Street 2:
Mailing Address - City:WADESBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28170-2474
Mailing Address - Country:US
Mailing Address - Phone:828-433-4567
Mailing Address - Fax:828-433-4576
Practice Address - Street 1:121 WORTHAM ST STE G
Practice Address - Street 2:
Practice Address - City:WADESBORO
Practice Address - State:NC
Practice Address - Zip Code:28170-2474
Practice Address - Country:US
Practice Address - Phone:828-433-4567
Practice Address - Fax:828-433-4576
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-24
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC29166101YP2500X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty