NOVA I.C. INC. - NPI NUMBER 1063438695

Summary

Provider Name: NOVA I.C. INC.

NPI Number: 1063438695

Clasification: Residential Treatment Facility, Mental Retardation and/or Developmental Disabilities (320600000X)

Address:
102 W PATETOWN RD
2307 NORWOOD AVENUE
GOLDSBORO, NC
ZIP 27530

Phone Number: (919) 751-1083



Detailed Information

NOVA I.C. INC. is a residential treatment facility, mental retardation and/or developmental disabilities in Goldsboro, NC. The provider is a residential facility that provides habilitation services and other care and treatment to adults or children diagnosed with developmental disabilities and/or mental retardation and are not able to live independently. The assigned NPI number for this provider is 1063438695 and is registered as an organization entity type.

The provider's business address is:

102 W PATETOWN RD
2307 NORWOOD AVENUE
GOLDSBORO, NC
ZIP 27530-415
Phone: (919) 751-1083
Fax: (919) 735-9643

The provider's authorized official is John E. Ford .
The authorized official title is Ceo President and has the following contact phone number (919) 735-8887.

The enumeration date for this NPI number is 7/15/2006 and was last updated on 7/28/2008.

Map - Location of Practice

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Taxonomy Codes

The following information regarding the scope of practice of this provider is available:

No. Taxonomy Code Taxonomy Clasification Taxonomy Specialization License Number License State Primary
1 320600000X Residential Treatment Facility, Mental Retardation and/or Developmental Disabilities NC Yes

Other (Legacy) Identifiers

The following legacy identifiers are available for this provider:

No. Other Provider Identifier Other Provider Identifier Type Other Provider Identifier State Other Provider Identifier Issuer
1 8300822 MEDICAID NC
2 8300826B MEDICAID NC
3 8300826 MEDICAID NC
4 6006439 MEDICAID NC
5 8300758B MEDICAID NC

NPI Record

No. Field Name Field Value
1 NPI 1063438695
2 Entity Type Code 2
3 Employer Identification Number EIN
4 Provider Organization Name Legal Business Name NOVA I.C. INC.
5 Provider First Line Business Practice Location Address 102 W PATETOWN RD
6 Provider Second Line Business Practice Location Address 2307 NORWOOD AVENUE
7 Provider Business Practice Location Address City Name GOLDSBORO
8 Provider Business Practice Location Address State Name NC
9 Provider Business Practice Location Address Postal Code 275301415
10 Provider Business Practice Location Address Country Code If outside U S US
11 Provider Business Practice Location Address Telephone Number 9197511083
12 Provider Business Practice Location Address Fax Number 9197359643
13 Provider Enumeration Date 7/15/2006
14 Last Update Date 7/28/2008
15 Authorized Official Last Name FORD
16 Authorized Official First Name JOHN
17 Authorized Official Middle Name E.
18 Authorized Official Title or Position CEO PRESIDENT
19 Authorized Official Telephone Number 9197358887
20 Healthcare Provider Taxonomy Code 1 320600000X
21 Provider License Number State Code 1 NC
22 Healthcare Provider Primary Taxonomy Switch 1 Y
23 Other Provider Identifier 1 8300822
24 Other Provider Identifier Type Code 1 05
25 Other Provider Identifier State 1 NC
26 Other Provider Identifier 2 8300826B
27 Other Provider Identifier Type Code 2 05
28 Other Provider Identifier State 2 NC
29 Other Provider Identifier 3 8300826
30 Other Provider Identifier Type Code 3 05
31 Other Provider Identifier State 3 NC
32 Other Provider Identifier 4 6006439
33 Other Provider Identifier Type Code 4 05
34 Other Provider Identifier State 4 NC
35 Other Provider Identifier 5 8300758B
36 Other Provider Identifier Type Code 5 05
37 Other Provider Identifier State 5 NC
38 Is Organization Subpart N
39 Authorized Official Name Prefix Text DR.
40 Authorized Official Credential Text PHD

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This page was last updated on: 7/15/2014
All materials and services on this site are provided on an "as is" and "as available" basis without warranty of any kind. The NPI record is maintained by the National Plan & Provider Enumeration System (NPPES) and anyone may request this information and other NPPES health care provider data from HHS under The Freedom of Information Act (FOIA), Title 5 of the United States Code, section 552. To update the NPI records please contact the NPPES.