Provider Demographics
NPI:1992768881
Name:VANCE-WARREN COMPREHENSIVE HEALTH PLAN, INC.
Entity type:Organization
Organization Name:VANCE-WARREN COMPREHENSIVE HEALTH PLAN, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:K
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-456-2181
Mailing Address - Street 1:1 OPPORTUNITY DRIVE
Mailing Address - Street 2:P. O. BOX 425
Mailing Address - City:MANSON
Mailing Address - State:NC
Mailing Address - Zip Code:27553-0425
Mailing Address - Country:US
Mailing Address - Phone:252-456-2181
Mailing Address - Fax:252-456-2115
Practice Address - Street 1:1 OPPORTUNITY DRIVE
Practice Address - Street 2:
Practice Address - City:MANSON
Practice Address - State:NC
Practice Address - Zip Code:27553-0425
Practice Address - Country:US
Practice Address - Phone:252-456-2181
Practice Address - Fax:252-456-2115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-11
Last Update Date:2008-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC344566CMedicaid
NC344566BMedicaid
NC344566DMedicaid
NC344566AMedicaid
NC344566BMedicaid
NC2333908Medicare PIN