Provider Demographics
NPI:1124172986
Name:MCIVER, JAMES EDWARD JR
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:EDWARD
Last Name:MCIVER
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 12364
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-2364
Mailing Address - Country:US
Mailing Address - Phone:910-347-5218
Mailing Address - Fax:910-346-0957
Practice Address - Street 1:141 THOMAS HUMPHREY RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-6205
Practice Address - Country:US
Practice Address - Phone:910-347-5218
Practice Address - Fax:910-346-0957
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-067-142322D00000X
NCMHL-067-162322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6603585Medicaid
NC8301087BMedicaid
NC6603978Medicaid