Provider Demographics
NPI:1124051867
Name:KATAM INC
Entity type:Organization
Organization Name:KATAM INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:WEST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-630-2105
Mailing Address - Street 1:PO BOX 64955
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28306-0955
Mailing Address - Country:US
Mailing Address - Phone:910-630-2105
Mailing Address - Fax:
Practice Address - Street 1:731 MCGILVARY ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-5406
Practice Address - Country:US
Practice Address - Phone:910-630-2105
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6603038Medicaid
NC6603306Medicaid
NC6604086Medicaid