Basic Information
| Provider Information | |||||||||
| NPI: | 1164468104 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THERAPEUTIC ALTERNATIVES INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | PROVIDENCE GROUP HOME | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 814 | ||||||||
| Address2: | |||||||||
| City: | RANDLEMAN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 273170814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3364952700 | ||||||||
| FaxNumber: | 3364955552 | ||||||||
| Practice Location | |||||||||
| Address1: | 941 E SALISBURY ST | ||||||||
| Address2: | |||||||||
| City: | ASHEBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272035049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3366251500 | ||||||||
| FaxNumber: | 3366252767 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2006 | ||||||||
| LastUpdateDate: | 06/13/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BURROW | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
| AuthorizedOfficialMiddleName: | ALAN | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3364952700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | N | Agencies | Community/Behavioral Health | 311ZA0620X | MHL076047 | NC | Y | Nursing & Custodial Care Facilities | Custodial Care Facility | Adult Care Home |
ID Information
| ID | Type | State | Issuer | Description | 3408682 | 05 | NC | MEDICAID | 7801237 | 05 | NC | MEDICAID |