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NOVA-IC INC. NPI 1043459852


NPI Information

NPI: 1043459852
Provider Name: NOVA-IC, INC.

Other Name: HOLLY STREET HOME

Classification: Intermediate Care Facility, Mentally Retarded - 315P00000X
Entity Type: Organization

CLIA Number: 34D2147871

Address:
1509 HOLLY STREET
GOLDSBORO, NC
ZIP 27534
Phone: (919) 735-4736
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NOVA-IC, INC. is an intermediate care facility mentally retarded in Goldsboro, NC. The provider is (1) A public institution for care of the mentally retarded or people with related conditions. (2) An institution giving active treatment to mentally retarded or developmentally disabled persons or persons with related conditions. The primary purpose of the institution is to provide health or rehabilitative services to such individuals. NOVA-IC, INC. NPI is 1043459852. The provider is registered as an organization entity type.
The provider Other Name Is Holly Street Home.

The provider's business location address is:

1509 HOLLY STREET
GOLDSBORO, NC
ZIP 27534-033
Phone: (919) 735-4736
Fax: (919) 735-6825

The provider's authorized official is Tracey Pridgen .
The authorized official title is Cfo and has the following contact phone number (919) 734-8803.

The CLIA number assigned to this NPI record is 34D2147871 - intermediate care facility/individuals with intellectual disability with a certificate type of Certificate of Waiver.

The enumeration date for this NPI number is 2/18/2009 and was last updated on 10/5/2021.


Taxonomy Codes

The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:

No.Taxonomy CodeTaxonomy ClasificationTaxonomy SpecializationLicense NumberLicense StatePrimary
1315P00000XIntermediate Care Facility, Mentally RetardedMHL-096-114NORTH CAROLINAYes

Other Identifiers

The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.

No.Other Provider IdentifierOther Provider Identifier TypeOther Provider Identifier StateOther Provider Identifier Issuer
13406312MEDICAIDNORTH CAROLINA

What is NPI?

NPI stands for National Provider Identifier. The NPI is a 10-digit identification number that is completely unique. The NPI number by itself does not contain any identifiable information such as a provider’s speciality or location. The NPI is assigned to individuals or organizacions for their lifespan and it is independent of key provider information type updates like a change of practices, location or speciality.

This page was last updated on: 11/14/2023

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