Organization
CLAY COUNTY
Active
Organization subpart
No
Provider details
NPI number
Authorized official
REVONDA MOSS (ADMINISTRATOR OFFICER)
(828) 389-6301
Entity
Organization
Contact information
Practice address
119 COURTHOUSE DR, HAYESVILLE, NC 28904-4968
(828) 389-6301
(828) 389-6427
Mailing address
PO BOX 147, HAYESVILLE, NC 28904-0147
(828) 389-6301
(828) 389-6427
Taxonomy
Speciality
Code
Description
License number
State
251B00000X
Case Management Agency
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
8700086
MEDICAID PROVIDER NUMBER
NC
Enumeration date
06/21/2007
Last updated
12/10/2020
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