Provider Demographics
NPI:1003047069
Name:MAGNANIMOUS GROUP HOME LLC
Entity Type:Organization
Organization Name:MAGNANIMOUS GROUP HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ISAIAH
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-382-9985
Mailing Address - Street 1:9407 HWY 41 W
Mailing Address - Street 2:
Mailing Address - City:PINK HILL
Mailing Address - State:NC
Mailing Address - Zip Code:28572-7021
Mailing Address - Country:US
Mailing Address - Phone:910-324-3276
Mailing Address - Fax:
Practice Address - Street 1:9407 HWY 41 W
Practice Address - Street 2:
Practice Address - City:PINK HILL
Practice Address - State:NC
Practice Address - Zip Code:28572-7021
Practice Address - Country:US
Practice Address - Phone:910-324-3276
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-06
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X, 385H00000X
NCMHL-052-016322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No251B00000XAgenciesCase Management
No385H00000XRespite Care FacilityRespite Care