Provider Demographics
NPI:1457584385
Name:COMMUNITY INTERVENTION CENTER, INC.
Entity Type:Organization
Organization Name:COMMUNITY INTERVENTION CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:
Authorized Official - Last Name:ST.CLAIR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-321-7710
Mailing Address - Street 1:PO BOX 30196
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27833-0196
Mailing Address - Country:US
Mailing Address - Phone:252-321-7710
Mailing Address - Fax:252-317-0516
Practice Address - Street 1:605 LYNNDALE CT STE A
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858-5449
Practice Address - Country:US
Practice Address - Phone:252-321-7710
Practice Address - Fax:252-317-0516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-26
Last Update Date:2009-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8301936Medicaid
NC8302079Medicaid