Provider Demographics
NPI:1437292364
Name:BYNUM'S PLACE LLC
Entity Type:Organization
Organization Name:BYNUM'S PLACE LLC
Other - Org Name:JEREMIAH'S PLACE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MOORE
Authorized Official - Middle Name:
Authorized Official - Last Name:BYNUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-915-9174
Mailing Address - Street 1:1455 BULLOCKSVILLE ROAD
Mailing Address - Street 2:
Mailing Address - City:MANSON
Mailing Address - State:NC
Mailing Address - Zip Code:27553-9765
Mailing Address - Country:US
Mailing Address - Phone:252-456-6534
Mailing Address - Fax:
Practice Address - Street 1:1455 BULLOCKSVILLE ROAD
Practice Address - Street 2:
Practice Address - City:MANSON
Practice Address - State:NC
Practice Address - Zip Code:27553-9765
Practice Address - Country:US
Practice Address - Phone:252-456-6534
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL091077320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC041247OtherFACILITY ID