Provider Demographics
NPI:1649443953
Name:JOHNSTON COUNTY INDUSTRIES, INC.
Entity type:Organization
Organization Name:JOHNSTON COUNTY INDUSTRIES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:R
Authorized Official - Last Name:SHORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-743-8702
Mailing Address - Street 1:1100 E PRESTON ST
Mailing Address - Street 2:
Mailing Address - City:SELMA
Mailing Address - State:NC
Mailing Address - Zip Code:27576-3162
Mailing Address - Country:US
Mailing Address - Phone:919-743-8709
Mailing Address - Fax:
Practice Address - Street 1:112 E RICHARDSON ST
Practice Address - Street 2:
Practice Address - City:SELMA
Practice Address - State:NC
Practice Address - Zip Code:27576-2606
Practice Address - Country:US
Practice Address - Phone:919-965-6892
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-08
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-051-162251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8302099Medicaid