Provider Demographics
NPI:1629192489
Name:LEE COUNTY GROUP HOMES INC.
Entity Type:Organization
Organization Name:LEE COUNTY GROUP HOMES INC.
Other - Org Name:LEE COUNTY GROUP HOMES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CELIA
Authorized Official - Middle Name:CAMERON
Authorized Official - Last Name:COUSINS
Authorized Official - Suffix:
Authorized Official - Credentials:QPBD
Authorized Official - Phone:919-776-9189
Mailing Address - Street 1:1576 KELLY DR
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27330-6428
Mailing Address - Country:US
Mailing Address - Phone:919-776-9189
Mailing Address - Fax:919-774-7711
Practice Address - Street 1:3101 CARBONTON RD
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:NC
Practice Address - Zip Code:27330-8214
Practice Address - Country:US
Practice Address - Phone:919-776-9189
Practice Address - Fax:919-774-7711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7804513261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCMHL-053-039Medicare ID - Type UnspecifiedGROUP HOME