Provider Demographics
NPI:1902928765
Name:PEOPLE OF POTENTIAL, INC
Entity Type:Organization
Organization Name:PEOPLE OF POTENTIAL, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENTIAL
Authorized Official - Prefix:MS
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:L
Authorized Official - Last Name:MCCULLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-989-1224
Mailing Address - Street 1:1001 HENDERSON DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28540-7423
Mailing Address - Country:US
Mailing Address - Phone:910-989-1224
Mailing Address - Fax:
Practice Address - Street 1:113 COURTLAND DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-6017
Practice Address - Country:US
Practice Address - Phone:910-989-1224
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEOPLE OF POTENTIAL INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-04
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL067034320800000X
NCMHL067100320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3409608Medicaid