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

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 Field Definition 1
1 NPI 1063438695 The 10-position all-numeric identification number assigned by the NPS to uniquely identify a health care provider. The NPI number includes an ISO standard check-digit in the 10th position. There is no intelligence about the health care provider in the number.
2 Entity Type Code 2 Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO).
3 Employer Identification Number EIN The Employer Identification Number (EIN), assigned by the IRS, of the provider being identified.
4 Provider Organization Name Legal Business Name NOVA I.C. INC. The name of the organization provider. If the provider is an organization, this is the legal business name.
5 Provider First Line Business Practice Location Address 102 W PATETOWN RD The first line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
6 Provider Second Line Business Practice Location Address 2307 NORWOOD AVENUE The second line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
7 Provider Business Practice Location Address City Name GOLDSBORO The city name in the location address of the provider being identified.
8 Provider Business Practice Location Address State Name NC The State code in the location of the provider being identified.
9 Provider Business Practice Location Address Postal Code 275301415 The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available.
10 Provider Business Practice Location Address Country Code If outside U S US The country code in the location address of the provider being identified.
11 Provider Business Practice Location Address Telephone Number 9197511083 The telephone number associated with the location address of the provider being identified.
12 Provider Business Practice Location Address Fax Number 9197359643 The fax number associated with the location address of the provider being identified.
13 Provider Enumeration Date 7/15/2006 The date the provider was assigned a unique identifier (assigned an NPI).
14 Last Update Date 7/28/2008 The date that a record was last updated or changed.
15 Authorized Official Last Name FORD The last name of the person authorized to submit the NPI application or to change NPS data for a health care provider.
16 Authorized Official First Name JOHN The first name of the authorized official.
17 Authorized Official Middle Name E. The middle name of the authorized official.
18 Authorized Official Title or Position CEO PRESIDENT The title or position of the authorized official.
19 Authorized Official Telephone Number 9197358887 The 10-position telephone number of the authorized official.
20 Healthcare Provider Taxonomy Code 1 320600000X Code designating the provider type, classification, and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1.
21 Provider License Number State Code 1 NC The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number.
22 Healthcare Provider Primary Taxonomy Switch 1 Y
23 Other Provider Identifier 1 8300822 Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form.
24 Other Provider Identifier Type Code 1 05 Code indicating the type of identifier currently or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form.
25 Other Provider Identifier State 1 NC
26 Other Provider Identifier 2 8300826B Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form.
27 Other Provider Identifier Type Code 2 05 Code indicating the type of identifier currently or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form.
28 Other Provider Identifier State 2 NC
29 Other Provider Identifier 3 8300826 Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form.
30 Other Provider Identifier Type Code 3 05 Code indicating the type of identifier currently or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form.
31 Other Provider Identifier State 3 NC
32 Other Provider Identifier 4 6006439 Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form.
33 Other Provider Identifier Type Code 4 05 Code indicating the type of identifier currently or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form.
34 Other Provider Identifier State 4 NC
35 Other Provider Identifier 5 8300758B Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form.
36 Other Provider Identifier Type Code 5 05 Code indicating the type of identifier currently or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form.
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: 4/19/2015

(1) Field Definition Source-. Federal Register / Vol. 69, No. 15 / Friday, January 23, 2004 / Rules and Regulations - Part II Department of Health and Human Services Office of the Secretary 45 CFR Part 162 HIPAA Administrative Simplification: Standard Unique Health Identifier for Health Care Providers; Final Rule

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