Provider Demographics
NPI:1427502558
Name:PROJECT 658
Entity type:Organization
Organization Name:PROJECT 658
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARJORIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LUGIBIHL
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:704-733-9934
Mailing Address - Street 1:3646 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28205-6064
Mailing Address - Country:US
Mailing Address - Phone:704-733-9934
Mailing Address - Fax:704-733-9925
Practice Address - Street 1:3622 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28205-5638
Practice Address - Country:US
Practice Address - Phone:704-910-5810
Practice Address - Fax:980-207-0214
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10040A106H00000X
NC238539163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty