Provider Demographics
NPI:1619105988
Name:OASIS CLINICAL CARE MANAGER, LLC
Entity type:Organization
Organization Name:OASIS CLINICAL CARE MANAGER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:THEODUS
Authorized Official - Middle Name:
Authorized Official - Last Name:ROACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-604-1437
Mailing Address - Street 1:6101 IDLEWILD RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28212-0517
Mailing Address - Country:US
Mailing Address - Phone:704-536-8381
Mailing Address - Fax:
Practice Address - Street 1:6101 IDLEWILD RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28212-0517
Practice Address - Country:US
Practice Address - Phone:704-536-8381
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-25
Last Update Date:2009-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0052151041C0700X
NCC0060531041C0700X
NCC0053191041C0700X
NCP0027251041C0700X
NC3676103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6107588Medicaid
NC6106359Medicaid
NC2011974Medicaid
NC89133JFMedicaid
NC6106363Medicaid
NC6107588Medicaid