Provider Demographics
NPI:1992990113
Name:FIDELITY FIRST HEALTH CARE SERVICES, LLC
Entity type:Organization
Organization Name:FIDELITY FIRST HEALTH CARE SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:QP, BA
Authorized Official - Phone:910-343-1003
Mailing Address - Street 1:3825 MARKET ST
Mailing Address - Street 2:SUITE 6
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-1453
Mailing Address - Country:US
Mailing Address - Phone:910-343-1003
Mailing Address - Fax:
Practice Address - Street 1:3825 MARKET ST
Practice Address - Street 2:SUITE 6
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-1453
Practice Address - Country:US
Practice Address - Phone:910-343-1003
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-11
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC251S00000X251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8301726BMedicaid