NPIMap

Organization Active NPI

Nova-Ic, Inc.

  • Intellectual Disabilities Intermediate Care Facility
  • Goldsboro, NC
National Provider Identifier
1043459852
Registry record updated Oct 8, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Intellectual Disabilities Intermediate Care FacilityTaxonomy code 315P00000X
License
MHL-096-114 Issued in NC
Legal business name
NOVA-IC, INC.
Practice address
1509 E Holly St
Goldsboro, NC 27530-3033
Phone
(919) 734-8803
Fax
(919) 735-6825
NPI assigned
Feb 18, 2009
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 8, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Tracey Pridgen, CPA
Title
Cfo
Phone
(919) 734-8803

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Intellectual Disabilities Intermediate Care Facility 315P00000X MHL-096-114 NC Primary

Addresses

Primary practice location

1509 E Holly St
Goldsboro, NC 27530-3033

Mailing address

PO Box 11077
Goldsboro, NC 27532-1077
Phone (919) 734-8803

Other identifiers 1

IdentifierTypeStateIssuer
3406312MedicaidNC

Other names 1

  • Holly street Home Other name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Not listed in the public Medicare enrollment file

Intermediate care facility for individuals with intellectual disabilities certification: CCN 34G178

Name & address match This certification has no NPI in the Medicare enrollment files. CMS publishes enrollment files for six facility types only, so it was connected to this NPI by matching the name and address CMS publishes for it.

Legal name
HOLLY STREET HOME
Certification status
Active
Provider type (POS)
Intermediate care facility for individuals with intellectual disabilities
Participating since
Mar 1, 1991
Last certification
Dec 16, 2025
Beds
6
Ownership / control type
Private (proprietary)
Facility address
1509 E Holly Street
Goldsboro, NC 27530

National Provider Directory

National Provider Directory
Tax ID family
Nova Ic Inc18 organizations share this tax ID, including this one

Other organizations with this tax ID 17

Organizations that report the same tax identification number in the National Provider Directory.

View all 17

Locations

1509 E Holly St
Goldsboro, NC 27530

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1234915200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1759881600000",
    "number": "1043459852",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 11077",
            "city": "GOLDSBORO",
            "state": "NC",
            "postal_code": "275321077",
            "telephone_number": "919-734-8803",
            "fax_number": "919-735-6825"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1509 E HOLLY ST",
            "city": "GOLDSBORO",
            "state": "NC",
            "postal_code": "275303033",
            "telephone_number": "919-734-8803",
            "fax_number": "919-735-6825"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NOVA-IC, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-02-18",
        "last_updated": "2025-10-08",
        "certification_date": "2025-10-08",
        "status": "A",
        "authorized_official_last_name": "PRIDGEN",
        "authorized_official_first_name": "TRACEY",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "919-734-8803",
        "authorized_official_credential": "CPA"
    },
    "taxonomies": [
        {
            "code": "315P00000X",
            "taxonomy_group": "",
            "desc": "Intermediate Care Facility, Intellectual Disabilities",
            "state": "NC",
            "license": "MHL-096-114",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "3406312",
            "state": "NC"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Holly street Home",
            "code": "5",
            "type": "Other Name"
        },
        {
            "organization_name": "Holly street Home",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Goldsboro, NC

Sources for this page

Verify at the official NPI Registry.