Provider Demographics
NPI:1629273610
Name:SYLVANGLADE HOME, INC.
Entity Type:Organization
Organization Name:SYLVANGLADE HOME, INC.
Other - Org Name:DONNELL GROUP HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:HATTIE
Authorized Official - Middle Name:CHEEKS
Authorized Official - Last Name:GRAVES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-621-8119
Mailing Address - Street 1:4915 SYLVANGLADE RD
Mailing Address - Street 2:
Mailing Address - City:MC LEANSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27301-9753
Mailing Address - Country:US
Mailing Address - Phone:336-358-2156
Mailing Address - Fax:
Practice Address - Street 1:4915 SYLVANGLADE RD
Practice Address - Street 2:
Practice Address - City:MC LEANSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27301-9753
Practice Address - Country:US
Practice Address - Phone:336-358-2156
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-19
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL041572320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities