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Organization
NOVA IC, INC.
Active
Organization
NOVA IC, INC.
Active
Other names
Washington Street East Group Home
Organization subpart
No
Provider details
NPI number
Authorized official
TRACEY PRIDGEN CPA (CFO)
(919) 734-8803
Entity
Organization
Contact information
Practice address
407 W. WASHINGTON STREET, LAGRANGE, NC 28551-1623
(919) 734-8803
(919) 735-6825
Mailing address
PO BOX 11077, GOLDSBORO, NC 27532-1077
(919) 734-8803
(919) 735-6825
Taxonomy
Speciality
Code
Description
License number
State
315P00000X
Intellectual Disabilities Intermediate Care Facility
Primary
MHL-054-038
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
340608V
—
NC
Enumeration date
02/18/2009
Last updated
10/08/2025
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