Provider Demographics
NPI:1801070719
Name:EAST COVE PSYCHIATRIC SERVICES PC
Entity type:Organization
Organization Name:EAST COVE PSYCHIATRIC SERVICES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/M.D.
Authorized Official - Prefix:MR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:SHANNON
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:252-523-2781
Mailing Address - Street 1:1305 N QUEEN ST
Mailing Address - Street 2:
Mailing Address - City:KINSTON
Mailing Address - State:NC
Mailing Address - Zip Code:28501-2965
Mailing Address - Country:US
Mailing Address - Phone:252-523-2781
Mailing Address - Fax:252-523-2711
Practice Address - Street 1:1305 N QUEEN ST
Practice Address - Street 2:
Practice Address - City:KINSTON
Practice Address - State:NC
Practice Address - Zip Code:28501-2965
Practice Address - Country:US
Practice Address - Phone:252-523-2781
Practice Address - Fax:252-523-2711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-27
Last Update Date:2010-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200301170261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health