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
StateLicense IDTaxonomies
NC251B00000X, 251C00000X, 251S00000X, 251T00000X, 251X00000X, 310400000X, 320600000X, 320700000X, 320800000X, 320900000X, 343800000X, 343900000X, 347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered251B00000XAgenciesCase Management
Not Answered251C00000XAgenciesDay Training, Developmentally Disabled Services
Not Answered251S00000XAgenciesCommunity/Behavioral Health
Not Answered251T00000XAgenciesProgram of All-Inclusive Care for the Elderly (PACE) Provider Organization
Not Answered251X00000XAgenciesSupports Brokerage
Not Answered310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Not Answered320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Not Answered320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
Not Answered320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Not Answered320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Not Answered343800000XTransportation ServicesSecured Medical Transport (VAN)
Not Answered343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Not Answered347C00000XTransportation ServicesPrivate Vehicle
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8300841Medicaid