Provider Demographics
NPI:1710023155
Name:PERSON COUNTY GROUP HOMES, INC
Entity Type:Organization
Organization Name:PERSON COUNTY GROUP HOMES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:W
Authorized Official - Last Name:FORSYTHE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-599-9421
Mailing Address - Street 1:PO BOX 721
Mailing Address - Street 2:
Mailing Address - City:ROXBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27573-0721
Mailing Address - Country:US
Mailing Address - Phone:336-599-9421
Mailing Address - Fax:336-599-7220
Practice Address - Street 1:202 N. MAIN STREET
Practice Address - Street 2:
Practice Address - City:ROXBORO
Practice Address - State:NC
Practice Address - Zip Code:27573-0721
Practice Address - Country:US
Practice Address - Phone:336-599-9421
Practice Address - Fax:336-599-7220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL 073 019320800000X, 320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7803468Medicaid