Provider Demographics
NPI:1861926792
Name:CARY CHURCH OF GOD
Entity type:Organization
Organization Name:CARY CHURCH OF GOD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DAN
Authorized Official - Middle Name:
Authorized Official - Last Name:TIREY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-467-0537
Mailing Address - Street 1:107 QUADE DR
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27513-7401
Mailing Address - Country:US
Mailing Address - Phone:919-467-0537
Mailing Address - Fax:
Practice Address - Street 1:107 QUADE DR
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27513-7401
Practice Address - Country:US
Practice Address - Phone:919-467-0537
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-18
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA12861101YP2500X
NC2014-010312084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty