Provider Demographics
NPI:1235323817
Name:WORTHAM'S GROUP HOME
Entity Type:Organization
Organization Name:WORTHAM'S GROUP HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALMEDA
Authorized Official - Middle Name:
Authorized Official - Last Name:WORTHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-257-0755
Mailing Address - Street 1:475 RIFLE RANGE ROAD
Mailing Address - Street 2:
Mailing Address - City:WARRENTON
Mailing Address - State:NC
Mailing Address - Zip Code:27589
Mailing Address - Country:US
Mailing Address - Phone:252-257-0755
Mailing Address - Fax:252-257-9147
Practice Address - Street 1:475 RIFLE RANGE ROAD
Practice Address - Street 2:
Practice Address - City:WARRENTON
Practice Address - State:NC
Practice Address - Zip Code:27589
Practice Address - Country:US
Practice Address - Phone:252-257-0755
Practice Address - Fax:252-257-9147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-28
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-093-0493747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty