Provider Demographics
NPI:1851524243
Name:NOVA INC
Entity Type:Organization
Organization Name:NOVA INC
Other - Org Name:PINEWOOD FACILITY
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:PRIDGEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-734-8803
Mailing Address - Street 1:PO BOX 11147
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27532-1147
Mailing Address - Country:US
Mailing Address - Phone:252-233-0491
Mailing Address - Fax:252-233-0495
Practice Address - Street 1:2002 A-B SHACKLEFORD ROAD
Practice Address - Street 2:
Practice Address - City:KINSTON
Practice Address - State:NC
Practice Address - Zip Code:28502-7476
Practice Address - Country:US
Practice Address - Phone:252-233-0491
Practice Address - Fax:252-233-0495
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-01
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-054-125323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3404550Medicaid
NC0032HOtherBCBSNC