Provider Demographics
NPI:1790913366
Name:COMMUNITY OUTREACH INTENSE FAMILY SERVICES, LLC
Entity Type:Organization
Organization Name:COMMUNITY OUTREACH INTENSE FAMILY SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-791-8104
Mailing Address - Street 1:109 PROFESSIONAL CT STE 107
Mailing Address - Street 2:
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529-8348
Mailing Address - Country:US
Mailing Address - Phone:919-791-8104
Mailing Address - Fax:919-266-0318
Practice Address - Street 1:1112 HADEL PL
Practice Address - Street 2:
Practice Address - City:KNIGHTDALE
Practice Address - State:NC
Practice Address - Zip Code:27545-7511
Practice Address - Country:US
Practice Address - Phone:919-791-8104
Practice Address - Fax:919-266-0318
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-23
Last Update Date:2009-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6604368Medicaid
NC6604326Medicaid