Provider Demographics
NPI:1285065243
Name:IMPERATIVE CHANGES OUTREACH
Entity type:Organization
Organization Name:IMPERATIVE CHANGES OUTREACH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDRE
Authorized Official - Middle Name:
Authorized Official - Last Name:GAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-367-1112
Mailing Address - Street 1:PO BOX 553
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27835-0553
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1710 W THIRD ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-1669
Practice Address - Country:US
Practice Address - Phone:252-367-1112
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-02
Last Update Date:2013-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health