Provider Demographics
NPI:1821442112
Name:KIDS IMAGINATION PLAY STATION
Entity Type:Organization
Organization Name:KIDS IMAGINATION PLAY STATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-848-1675
Mailing Address - Street 1:156 RYE LN
Mailing Address - Street 2:
Mailing Address - City:RAEFORD
Mailing Address - State:NC
Mailing Address - Zip Code:28376-5301
Mailing Address - Country:US
Mailing Address - Phone:910-848-1675
Mailing Address - Fax:
Practice Address - Street 1:156 RYE LN
Practice Address - Street 2:
Practice Address - City:RAEFORD
Practice Address - State:NC
Practice Address - Zip Code:28376-5301
Practice Address - Country:US
Practice Address - Phone:910-848-1675
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-22
Last Update Date:2016-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency