Provider Demographics
NPI:1518135235
Name:PROFESSIONAL GROUP LIVING, LLC
Entity Type:Organization
Organization Name:PROFESSIONAL GROUP LIVING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:NATALKA
Authorized Official - Middle Name:LOCK
Authorized Official - Last Name:MASSEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-475-5845
Mailing Address - Street 1:715 B SOUTH WEST BLVD.
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:NC
Mailing Address - Zip Code:28328-4636
Mailing Address - Country:US
Mailing Address - Phone:910-592-2338
Mailing Address - Fax:
Practice Address - Street 1:715 B SOUTHWEST BLVD.
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NC
Practice Address - Zip Code:28328-4636
Practice Address - Country:US
Practice Address - Phone:910-592-2338
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-15
Last Update Date:2008-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services