Provider Demographics
NPI:1386883296
Name:POLK COUNTY COMMUNITY HEALTH & WELLNESS CENTER, INC
Entity type:Organization
Organization Name:POLK COUNTY COMMUNITY HEALTH & WELLNESS CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARY JO
Authorized Official - Middle Name:
Authorized Official - Last Name:STARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-894-2222
Mailing Address - Street 1:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:NC
Mailing Address - Zip Code:28722-0130
Mailing Address - Country:US
Mailing Address - Phone:828-894-2222
Mailing Address - Fax:
Practice Address - Street 1:801 W MILLS ST STE A&B
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:NC
Practice Address - Zip Code:28722-8494
Practice Address - Country:US
Practice Address - Phone:828-894-2222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-17
Last Update Date:2009-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6102994Medicaid
NC7912153Medicaid
NC6005017Medicaid
NC1740484575OtherNPI
NC6106296Medicaid
NC6000122Medicaid
NC6102994Medicaid
NC6005017Medicaid
NC1740484575OtherNPI