Provider Demographics
NPI:1164772489
Name:PITT COUNTY GROUP HOME BOARD FOR MENTALLY RETARDED, AUTISTIC PERSONS,
Entity Type:Organization
Organization Name:PITT COUNTY GROUP HOME BOARD FOR MENTALLY RETARDED, AUTISTIC PERSONS,
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:GRACE
Authorized Official - Last Name:BRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-524-4950
Mailing Address - Street 1:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:GRIFTON
Mailing Address - State:NC
Mailing Address - Zip Code:28530-0009
Mailing Address - Country:US
Mailing Address - Phone:252-524-4950
Mailing Address - Fax:252-524-3870
Practice Address - Street 1:2240 EDGEWATER DR
Practice Address - Street 2:
Practice Address - City:WINTERVILLE
Practice Address - State:NC
Practice Address - Zip Code:28590-9601
Practice Address - Country:US
Practice Address - Phone:252-524-4950
Practice Address - Fax:252-524-3870
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-13
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-074-037320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7802610Medicaid