Provider Demographics
NPI:1962556696
Name:EASTER SEALS UCP NORTH CAROLINA
Entity type:Organization
Organization Name:EASTER SEALS UCP NORTH CAROLINA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:NASHEBA
Authorized Official - Middle Name:YVETTE
Authorized Official - Last Name:KEY-ALLRED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-865-8632
Mailing Address - Street 1:5700 EXECUTIVE CENTER DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28212-8858
Mailing Address - Country:US
Mailing Address - Phone:704-566-6040
Mailing Address - Fax:704-971-2537
Practice Address - Street 1:3405 W WENDOVER AVE STE H
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27407-1525
Practice Address - Country:US
Practice Address - Phone:336-272-9602
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8301056BMedicaid
NC8301056GMedicaid
NC8301056HMedicaid
NC8301056IMedicaid