NPIMap

Organization Active NPI

Nova Ic, Inc.

  • Intellectual Disabilities Intermediate Care Facility
  • La Grange, NC
National Provider Identifier
1447499330
Registry record updated Sep 23, 2026
On this page

Key facts

NPPES NPI Registry
Primary specialty
Intellectual Disabilities Intermediate Care FacilityTaxonomy code 315P00000X
License
MHL-054-019 Issued in NC
Legal business name
NOVA IC, INC.
Practice address
405 W Washington St
La Grange, NC 28551-1623
Phone
(919) 734-8803
Fax
(919) 735-6825
NPI assigned
Feb 17, 2009
Last updated
Sep 23, 2026By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 23, 2026

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

Authorized official

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

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Intellectual Disabilities Intermediate Care Facility 315P00000X MHL-054-019 NC Primary

Addresses

Primary practice location

405 W Washington St
La Grange, NC 28551-1623

Mailing address

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

Other identifiers 1

IdentifierTypeStateIssuer
3406289MedicaidNC

Other names 1

  • LaGrange Home Other name

Medicare participation

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

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1447499330. Details of each certification follow.

  • CCN 34G171 Intermediate care facility for individuals with intellectual disabilities · Active · Name & address match · Details

Intermediate care facility for individuals with intellectual disabilities certification: CCN 34G171

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
LAGRANGE HOME
Certification status
Active
Provider type (POS)
Intermediate care facility for individuals with intellectual disabilities
Participating since
Jan 30, 1991
Last certification
May 6, 2025
Beds
6
Ownership / control type
Private (proprietary)
Facility address
405 West Washington Street
La Grange, NC 28551

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

405 W Washington St
La Grange, NC 28551

NPI Registry JSON

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

{
    "created_epoch": "1234828800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1790121600000",
    "number": "1447499330",
    "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": "405 W WASHINGTON ST",
            "city": "LA GRANGE",
            "state": "NC",
            "postal_code": "285511623",
            "telephone_number": "919-734-8803",
            "fax_number": "919-735-6825"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NOVA IC, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-02-17",
        "last_updated": "2026-09-23",
        "certification_date": "2026-09-23",
        "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"
    },
    "taxonomies": [
        {
            "code": "315P00000X",
            "taxonomy_group": "",
            "desc": "Intermediate Care Facility, Intellectual Disabilities",
            "state": "NC",
            "license": "MHL-054-019",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "3406289",
            "state": "NC"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "LaGrange Home",
            "code": "5",
            "type": "Other Name"
        },
        {
            "organization_name": "LaGrange Home",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in La Grange, NC

Sources for this page

Verify at the official NPI Registry.