Provider Demographics
NPI:1932394632
Name:POTTER'S HOUSE OF BEAUFORT COUNTY, INC.
Entity Type:Organization
Organization Name:POTTER'S HOUSE OF BEAUFORT COUNTY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TONYA
Authorized Official - Middle Name:
Authorized Official - Last Name:WOOLARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-946-6390
Mailing Address - Street 1:405 N MARKET ST
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27889-4935
Mailing Address - Country:US
Mailing Address - Phone:252-946-6390
Mailing Address - Fax:252-946-3847
Practice Address - Street 1:319 E 11TH ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:NC
Practice Address - Zip Code:27889-3716
Practice Address - Country:US
Practice Address - Phone:252-946-6390
Practice Address - Fax:252-946-3847
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-06
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL 007 031251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6603383Medicaid