Provider Demographics
NPI:1144375767
Name:OCTOBER ROAD INC.
Entity type:Organization
Organization Name:OCTOBER ROAD INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:HENDRICKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-940-0407
Mailing Address - Street 1:119 TUNNEL RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28805-1869
Mailing Address - Country:US
Mailing Address - Phone:828-350-1000
Mailing Address - Fax:828-350-1300
Practice Address - Street 1:119 TUNNEL RD STE B
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28805-1800
Practice Address - Country:US
Practice Address - Phone:828-350-1000
Practice Address - Fax:828-350-1300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMLH-011-272101YA0400X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MHL-011-272OtherNC DHSR
NC5905845Medicaid
NC6006159Medicaid
NC8703016Medicaid
NC3410004Medicaid
NC8305312Medicaid
NC3410004Medicaid