Provider Demographics
NPI:1609906288
Name:EDWARDS GROUP HOME 4
Entity Type:Organization
Organization Name:EDWARDS GROUP HOME 4
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCOLLUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-747-4000
Mailing Address - Street 1:PO BOX 295
Mailing Address - Street 2:
Mailing Address - City:SNOW HILL
Mailing Address - State:NC
Mailing Address - Zip Code:28580-0295
Mailing Address - Country:US
Mailing Address - Phone:252-747-4000
Mailing Address - Fax:252-747-2602
Practice Address - Street 1:1269 APPLE TREE RD
Practice Address - Street 2:
Practice Address - City:STANTONSBURG
Practice Address - State:NC
Practice Address - Zip Code:27883-9039
Practice Address - Country:US
Practice Address - Phone:252-747-4000
Practice Address - Fax:252-747-2602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2008-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL040027320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7805335OtherPROVIDER NUMBER