Provider Demographics
NPI:1659775989
Name:MCRAE, BOBBY
Entity Type:Individual
Prefix:
First Name:BOBBY
Middle Name:
Last Name:MCRAE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2542
Mailing Address - Street 2:
Mailing Address - City:ALBEMARLE
Mailing Address - State:NC
Mailing Address - Zip Code:28002-2542
Mailing Address - Country:US
Mailing Address - Phone:704-961-6797
Mailing Address - Fax:
Practice Address - Street 1:299 THOMASVILLE CH.RD.
Practice Address - Street 2:
Practice Address - City:MT GILEAD
Practice Address - State:NC
Practice Address - Zip Code:27306
Practice Address - Country:US
Practice Address - Phone:704-961-6797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-15
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
320600000320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities