Provider Demographics
NPI: | 1497891832 |
---|---|
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: | DAVID |
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: | PO 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 STREET |
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: | 2007-01-30 |
Last Update Date: | 2020-08-22 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NC | 251B00000X, 251C00000X, 251S00000X, 251T00000X, 251X00000X, 310400000X, 320600000X, 320700000X, 320800000X, 320900000X, 343800000X, 343900000X, 347C00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Not Answered | 251B00000X | Agencies | Case Management | |
Not Answered | 251C00000X | Agencies | Day Training, Developmentally Disabled Services | |
Not Answered | 251S00000X | Agencies | Community/Behavioral Health | |
Not Answered | 251T00000X | Agencies | Program of All-Inclusive Care for the Elderly (PACE) Provider Organization | |
Not Answered | 251X00000X | Agencies | Supports Brokerage | |
Not Answered | 310400000X | Nursing & Custodial Care Facilities | Assisted Living Facility | |
Not Answered | 320600000X | Residential Treatment Facilities | Residential Treatment Facility, Intellectual and/or Developmental Disabilities | |
Not Answered | 320700000X | Residential Treatment Facilities | Residential Treatment Facility, Physical Disabilities | |
Not Answered | 320800000X | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness | |
Not Answered | 320900000X | Residential Treatment Facilities | Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities | |
Not Answered | 343800000X | Transportation Services | Secured Medical Transport (VAN) | |
Not Answered | 343900000X | Transportation Services | Non-emergency Medical Transport (VAN) | |
Not Answered | 347C00000X | Transportation Services | Private Vehicle |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NC | 8300841 | Medicaid |