Provider Demographics
NPI:1174795165
Name:ASD-PCS-DURHAM
Entity type:Organization
Organization Name:ASD-PCS-DURHAM
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:VERONICA
Authorized Official - Middle Name:K
Authorized Official - Last Name:MCLENDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-549-1659
Mailing Address - Street 1:8430 UNIVERSITY EXEC PARK DR
Mailing Address - Street 2:SUITE 655
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-1350
Mailing Address - Country:US
Mailing Address - Phone:704-549-1659
Mailing Address - Fax:704-549-1664
Practice Address - Street 1:3600 N DUKE ST
Practice Address - Street 2:SUITE 103
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-1709
Practice Address - Country:US
Practice Address - Phone:919-471-1800
Practice Address - Fax:919-471-1877
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ANGEL STAR OF DURHAM, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-31
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC1308251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6600379Medicaid