Provider Demographics
NPI:1336285337
Name:PERSON COUNTY GROUP HOMES INC
Entity Type:Organization
Organization Name:PERSON COUNTY GROUP HOMES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVIDW
Authorized Official - Middle Name:W
Authorized Official - Last Name:FORSYTHE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-599-9421
Mailing Address - Street 1:P O BOX 721
Mailing Address - Street 2:
Mailing Address - City:ROXBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27573-0721
Mailing Address - Country:US
Mailing Address - Phone:336-599-9421
Mailing Address - Fax:336-599-7220
Practice Address - Street 1:202 N MAIN ST.
Practice Address - Street 2:
Practice Address - City:ROXBORO
Practice Address - State:NC
Practice Address - Zip Code:27573-0721
Practice Address - Country:US
Practice Address - Phone:336-599-9421
Practice Address - Fax:336-599-7220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC251C00000X, 251X00000X, 315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered251C00000XAgenciesDay Training, Developmentally Disabled Services
Not Answered251X00000XAgenciesSupports Brokerage
Not Answered315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC340607WMedicaid