Provider Demographics
NPI:1912051913
Name:MICAH'S MANAGEMENT SERVICES
Entity Type:Organization
Organization Name:MICAH'S MANAGEMENT SERVICES
Other - Org Name:MICAH'S ANGELS INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAULETTE
Authorized Official - Middle Name:L
Authorized Official - Last Name:WASHINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-712-8454
Mailing Address - Street 1:1909 J N PEASE PL
Mailing Address - Street 2:SUITE 204
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-4558
Mailing Address - Country:US
Mailing Address - Phone:704-712-8454
Mailing Address - Fax:704-532-4414
Practice Address - Street 1:1909 J N PEASE PL
Practice Address - Street 2:SUITE 204
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-4558
Practice Address - Country:US
Practice Address - Phone:704-712-8454
Practice Address - Fax:704-532-4414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2009-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC251B00000X251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8301861Medicaid