Provider Demographics
NPI:1356339154
Name:BLACK RIVER HEALTH SERVICES INC
Entity type:Organization
Organization Name:BLACK RIVER HEALTH SERVICES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LEEANN
Authorized Official - Middle Name:
Authorized Official - Last Name:AMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-259-6973
Mailing Address - Street 1:301 S CAMPBELL ST
Mailing Address - Street 2:
Mailing Address - City:BURGAW
Mailing Address - State:NC
Mailing Address - Zip Code:28425-5011
Mailing Address - Country:US
Mailing Address - Phone:910-259-6973
Mailing Address - Fax:910-259-6975
Practice Address - Street 1:4811 NC HIGHWAY 50
Practice Address - Street 2:
Practice Address - City:MAPLE HILL
Practice Address - State:NC
Practice Address - Zip Code:28454-8153
Practice Address - Country:US
Practice Address - Phone:910-259-6444
Practice Address - Fax:910-259-6659
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-06
Last Update Date:2020-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC344622ACMedicaid
0176JOtherBCBS
NC343904Medicare Oscar/Certification