1336661826 NPI number — GREATER VISION COUNSELING & CONSULTING AGENCY PLLC

Table of content: (NPI 1336661826)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336661826 NPI number — GREATER VISION COUNSELING & CONSULTING AGENCY PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GREATER VISION COUNSELING & CONSULTING AGENCY PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336661826
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/27/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
199 PINE TREE LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RAEFORD
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28376-2430
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-336-3554
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
402 HARRIS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RAEFORD
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28376-3112
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-336-3554
Provider Business Practice Location Address Fax Number:
910-875-5008
Provider Enumeration Date:
07/17/2017

Additional Information

Authorized Official

Authorized Official Last Name:
TILLMAN
Authorized Official First Name:
LUEVELYN
Authorized Official Middle Name:
JACOBS
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
910-336-3554

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  P009630 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3245S0500X , with the licence number: 21969 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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