Provider Demographics
NPI:1235328881
Name:MY SAVIOR FAMILY CARE HOME, INC.
Entity Type:Organization
Organization Name:MY SAVIOR FAMILY CARE HOME, INC.
Other - Org Name:PEOPLE OF PURPOSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:BARNES
Authorized Official - Last Name:BOONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-347-4451
Mailing Address - Street 1:PO BOX 20702
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27858-0702
Mailing Address - Country:US
Mailing Address - Phone:252-347-4451
Mailing Address - Fax:252-321-4829
Practice Address - Street 1:3200 BRIARCLIFF DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-4948
Practice Address - Country:US
Practice Address - Phone:252-347-4451
Practice Address - Fax:252-321-4829
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-19
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL074154322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6604098Medicaid