Basic Information
| Provider Information | |||||||||
| NPI: | 1629328943 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PITT COUNTY GROUP HOME BOARD FOR MENTALLY RETARDED, AUTISTIC PERSONS, | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9 | ||||||||
| Address2: | |||||||||
| City: | GRIFTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285300009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2525244950 | ||||||||
| FaxNumber: | 2525243870 | ||||||||
| Practice Location | |||||||||
| Address1: | 1203 RED BANKS RD | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278585302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2525244950 | ||||||||
| FaxNumber: | 2525243870 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2012 | ||||||||
| LastUpdateDate: | 09/13/2012 | ||||||||
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| AuthorizedOfficialLastName: | BRIGHT | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | GRACE | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2525244950 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320600000X | MHL-074-021 | NC | Y | Residential Treatment Facilities | Residential Treatment Facility, Mental Retardation and/or Developmental Disabilities |
ID Information
| ID | Type | State | Issuer | Description | 7802576 | 05 | NC | MEDICAID |