Basic Information
| Provider Information | |||||||||
| NPI: | 1295046290 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NEW RIVER SERVICE AUTHORITY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | NEW RIVER BEHAVIORAL HEALTHCARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 895 STATE FARM RD | ||||||||
| Address2: | SUITE 508 | ||||||||
| City: | BOONE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286074917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282649007 | ||||||||
| FaxNumber: | 8282625687 | ||||||||
| Practice Location | |||||||||
| Address1: | 132 POPLAR GROVE CONNECTOR | ||||||||
| Address2: | SUITE B | ||||||||
| City: | BOONE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286075915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282648759 | ||||||||
| FaxNumber: | 8282625687 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2010 | ||||||||
| LastUpdateDate: | 06/24/2010 | ||||||||
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| AuthorizedOfficialLastName: | BUCHANAN | ||||||||
| AuthorizedOfficialFirstName: | DONNA | ||||||||
| AuthorizedOfficialMiddleName: | GAYLE | ||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER PANEL MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8282635666 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | MHL095041 | NC | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 6005960 | 05 | NC | MEDICAID | 081NN | 01 | NC | BCBS | OTHER |