Basic Information
| Provider Information | |||||||||
| NPI: | 1023132560 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY HOUSING GROUP HOME | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3050 11TH AVENUE DR SE | ||||||||
| Address2: | |||||||||
| City: | HICKORY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286028336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286955900 | ||||||||
| FaxNumber: | 8286954256 | ||||||||
| Practice Location | |||||||||
| Address1: | 1018 5TH ST SE | ||||||||
| Address2: | |||||||||
| City: | HICKORY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286955900 | ||||||||
| FaxNumber: | 8286954256 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2007 | ||||||||
| LastUpdateDate: | 05/15/2018 | ||||||||
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| AuthorizedOfficialLastName: | LYNCH | ||||||||
| AuthorizedOfficialFirstName: | SHARON | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | FINANCIAL MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8286955900 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | N | Agencies | Community/Behavioral Health | 320900000X | Y | Residential Treatment Facilities | Community Based Residential Treatment, Mental Retardation and/or Developmental Disabilities |
ID Information
| ID | Type | State | Issuer | Description | 7805708 | 05 | NC | MEDICAID |