NPIMap

Organization Active NPI

Extended Reach Daytreatment for Childrena and Adolescents LLC

  • Case Management Agency
  • Fayetteville, NC
National Provider Identifier
1740587591
Registry record updated Feb 14, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
Case Management AgencyTaxonomy code 251B00000X
Legal business name
EXTENDED REACH DAYTREATMENT FOR CHILDRENA AND ADOLESCENTS LLC
Practice address
302 Bradford Ave
Fayetteville, NC 28301-5406
Phone
(910) 484-0095
Fax
(919) 238-7287
NPI assigned
Feb 14, 2011
Last updated
Feb 14, 2011By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 14, 2011

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

Authorized official

Name
Mr. Andrea Monique Boatman-Hall
Title
Ceo
Phone
(910) 229-8256

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Case Management Agency 251B00000X NU Primary

Addresses

Primary practice location

302 Bradford Ave
Fayetteville, NC 28301-5406

Mailing address

302 Bradford Ave
Fayetteville, NC 28301-5406
Phone (910) 484-0095

Other identifiers 3

IdentifierTypeStateIssuer
8302981MedicaidNC
8302339MedicaidNC
6006927MedicaidNC

National Provider Directory

National Provider Directory
Tax ID family
Extended Reach Day Treatment for Children Adolescents LLC3 organizations share this tax ID, including this one

Other organizations with this tax ID 2

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

Locations

302 Bradford Ave
Fayetteville, NC 28301
Phone (910) 484-0095

NPI Registry JSON

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

{
    "created_epoch": "1297641600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1297641600000",
    "number": "1740587591",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "302 BRADFORD AVE",
            "city": "FAYETTEVILLE",
            "state": "NC",
            "postal_code": "283015406",
            "telephone_number": "910-484-0095"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "302 BRADFORD AVE",
            "city": "FAYETTEVILLE",
            "state": "NC",
            "postal_code": "283015406",
            "telephone_number": "910-484-0095",
            "fax_number": "919-238-7287"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EXTENDED REACH DAYTREATMENT FOR CHILDRENA AND ADOLESCENTS LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-02-14",
        "last_updated": "2011-02-14",
        "status": "A",
        "authorized_official_last_name": "BOATMAN-HALL",
        "authorized_official_first_name": "ANDREA",
        "authorized_official_middle_name": "MONIQUE",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "910-229-8256",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "251B00000X",
            "taxonomy_group": "",
            "desc": "Case Management",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "8302981",
            "state": "NC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "8302339",
            "state": "NC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "6006927",
            "state": "NC"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Fayetteville, NC

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 14, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.