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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