Provider Demographics
NPI:1881834653
Name:EASTER SEALS UCP NORTH CAROLINA& VIRGINIA, INC
Entity Type:Organization
Organization Name:EASTER SEALS UCP NORTH CAROLINA& VIRGINIA, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTRACT ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:P
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-783-8898
Mailing Address - Street 1:5171 GLENWOOD AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-3266
Mailing Address - Country:US
Mailing Address - Phone:919-783-8898
Mailing Address - Fax:919-782-5486
Practice Address - Street 1:1503 WAYNE MEMORIAL DR
Practice Address - Street 2:UNIT E
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27534-2203
Practice Address - Country:US
Practice Address - Phone:919-587-0001
Practice Address - Fax:919-587-0007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-06
Last Update Date:2015-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8300746BMedicaid
NC8300746FMedicaid
NC8300746IMedicaid
NC8300746HMedicaid