Provider Demographics
NPI:1417045188
Name:CONCORDIA SUPPORT SERVICES, LLC
Entity type:Organization
Organization Name:CONCORDIA SUPPORT SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MEREDITH
Authorized Official - Middle Name:
Authorized Official - Last Name:NICKELBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-826-8253
Mailing Address - Street 1:PO BOX 26108
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-5018
Mailing Address - Country:US
Mailing Address - Phone:910-826-8253
Mailing Address - Fax:910-826-8254
Practice Address - Street 1:2315 BLOOM AVENUE
Practice Address - Street 2:SUITE 2
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-6165
Practice Address - Country:US
Practice Address - Phone:910-826-8253
Practice Address - Fax:910-826-8254
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2009-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251C00000X, 251S00000X, 320900000X
NCMHL-067-156320600000X
NCMHL-067154320600000X
NCMHL-047-070320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8300606Medicaid
NC8301129GMedicaid
NC6603837Medicaid
NC8300606BMedicaid
NC8300606GMedicaid
NC6006251Medicaid
NC6603570Medicaid
NC8300604Medicaid
NC8300605BMedicaid
NC8301129HMedicaid
NC6603687Medicaid
NC8300605Medicaid
NC5950244Medicaid
NC8301864BMedicaid
NC83001129BMedicaid
NC8300604BMedicaid
NC8301129Medicaid
NC8301864Medicaid