Provider Demographics
NPI:1265713606
Name:TYSON'S CORNER HEALTH SERVICES, INC.
Entity type:Organization
Organization Name:TYSON'S CORNER HEALTH SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:CASPERTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:HAWKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-407-8469
Mailing Address - Street 1:2100 N HERITAGE ST
Mailing Address - Street 2:UNIT B
Mailing Address - City:KINSTON
Mailing Address - State:NC
Mailing Address - Zip Code:28501-2222
Mailing Address - Country:US
Mailing Address - Phone:252-407-8469
Mailing Address - Fax:
Practice Address - Street 1:600 N GRACE ST
Practice Address - Street 2:UNIT D
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-4843
Practice Address - Country:US
Practice Address - Phone:252-407-8469
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-30
Last Update Date:2014-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 101YA0400X, 101Y00000X
NC251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6008809Medicaid
NC5921354Medicaid