Provider Demographics
NPI:1184761660
Name:C-BLAC SERVICES, INC.
Entity type:Organization
Organization Name:C-BLAC SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JANET
Authorized Official - Middle Name:M
Authorized Official - Last Name:WISE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-989-1786
Mailing Address - Street 1:1302 W MARKET ST
Mailing Address - Street 2:
Mailing Address - City:SMITHFIELD
Mailing Address - State:NC
Mailing Address - Zip Code:27577-3339
Mailing Address - Country:US
Mailing Address - Phone:919-989-1786
Mailing Address - Fax:919-989-1791
Practice Address - Street 1:1300 W MARKET ST
Practice Address - Street 2:
Practice Address - City:SMITHFIELD
Practice Address - State:NC
Practice Address - Zip Code:27577-3339
Practice Address - Country:US
Practice Address - Phone:919-989-1786
Practice Address - Fax:919-989-1791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL 051 128251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5901780Medicaid
NC6005614Medicaid
NC6600860Medicaid
NC8301075Medicaid
NC8700356Medicaid