Provider Demographics
NPI:1871681551
Name:CONCORDIA, SEABROOKS, & MILES PTNRS
Entity Type:Organization
Organization Name:CONCORDIA, SEABROOKS, & MILES PTNRS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MEREDITH
Authorized Official - Middle Name:
Authorized Official - Last Name:NICKELBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-826-8253
Mailing Address - Street 1:PO BOX 26108
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-5018
Mailing Address - Country:US
Mailing Address - Phone:910-826-8253
Mailing Address - Fax:910-826-8254
Practice Address - Street 1:1903 BRAGG BLVD
Practice Address - Street 2:SUITE 4
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-4563
Practice Address - Country:US
Practice Address - Phone:910-826-8253
Practice Address - Fax:910-826-8254
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-067-154320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6603570Medicaid
NC6603687Medicaid