Provider Demographics
NPI:1114069119
Name:MY BROTHERS HOUSE INC.
Entity Type:Organization
Organization Name:MY BROTHERS HOUSE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-532-4770
Mailing Address - Street 1:4822 ALBEMARLE RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28205-6668
Mailing Address - Country:US
Mailing Address - Phone:704-532-4770
Mailing Address - Fax:
Practice Address - Street 1:4822 ALBEMARLE RD STE 105
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28205-6612
Practice Address - Country:US
Practice Address - Phone:704-532-4770
Practice Address - Fax:704-532-4774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X, 320800000X
NC060-757323P00000X
NC060-538323P00000X
NC060-467323P00000X
NC092-519323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
No251S00000XAgenciesCommunity/Behavioral Health
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness