Provider Demographics
NPI:1942333240
Name:SPIRIT OF EXCELLENCE COMMUNITY OUTREACH,INC.
Entity Type:Organization
Organization Name:SPIRIT OF EXCELLENCE COMMUNITY OUTREACH,INC.
Other - Org Name:GUARDIAN CARE 1, 2, 3, 4, CHANGING LIVES, SAFE HAVEN,BRIDGE OF HOPE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:HELEN
Authorized Official - Middle Name:DELORISE
Authorized Official - Last Name:FLUDD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-382-6595
Mailing Address - Street 1:PO BOX 752
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28541-0752
Mailing Address - Country:US
Mailing Address - Phone:910-939-4663
Mailing Address - Fax:910-939-5079
Practice Address - Street 1:123 HENDERSON DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28540-5601
Practice Address - Country:US
Practice Address - Phone:910-939-4663
Practice Address - Fax:910-939-5079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X, 251E00000X, 251S00000X, 261QD1600X, 261QM0850X, 311ZA0620X, 320800000X, 320900000X
NCMHL-067-164323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3418119Medicaid
NC8301352Medicaid
NC8301352GMedicaid
NC3408311Medicaid
NC6602173Medicaid
NC001GMOtherBLUE CROSS BLUE SHIELD
NC009EJOtherBLUE CROSS BLUE SHIELD
NC6006360Medicaid
NC7805061Medicaid
NC6601227Medicaid
NC8301352BMedicaid