Basic Information
| Provider Information | |||||||||
| NPI: | 1841496015 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JOHNSTON COUNTY GROUP HOMES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1768 | ||||||||
| Address2: | |||||||||
| City: | SMITHFIELD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275771768 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199650340 | ||||||||
| FaxNumber: | 9199650340 | ||||||||
| Practice Location | |||||||||
| Address1: | 505 WEST BLANCHE ST. | ||||||||
| Address2: | |||||||||
| City: | PINE LEVEL | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27568 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199650158 | ||||||||
| FaxNumber: | 9199650158 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | HARPER | ||||||||
| AuthorizedOfficialFirstName: | JANET | ||||||||
| AuthorizedOfficialMiddleName: | GAIL | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9199650340 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 315P00000X | MHL-051-113 | NC | Y | Nursing & Custodial Care Facilities | Intermediate Care Facility, Mentally Retarded |
ID Information
| ID | Type | State | Issuer | Description | 3408949 | 05 | NC | MEDICAID | 7804465 | 05 | NC | MEDICAID |