Provider Demographics
NPI:1528315595
Name:NEW IMAGE
Entity type:Organization
Organization Name:NEW IMAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.E.O
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:
Authorized Official - Last Name:POWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-267-2833
Mailing Address - Street 1:408 SHEPARD ST
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-5260
Mailing Address - Country:US
Mailing Address - Phone:252-267-2833
Mailing Address - Fax:
Practice Address - Street 1:408 SHEPARD ST
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-5260
Practice Address - Country:US
Practice Address - Phone:252-267-2833
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-09
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5354758320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC=========Medicaid
NC=========OtherMEDICAID NUMBER FOR BUSINESS