Provider Demographics
NPI:1760544712
Name:PELHAM SUPPORTIVE SERVICES
Entity Type:Organization
Organization Name:PELHAM SUPPORTIVE SERVICES
Other - Org Name:PELHAM GROUP HOME #1
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MILDRED
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-630-6757
Mailing Address - Street 1:949 COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28301-2907
Mailing Address - Country:US
Mailing Address - Phone:910-630-6757
Mailing Address - Fax:910-884-9806
Practice Address - Street 1:1712 SHILOH DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-4027
Practice Address - Country:US
Practice Address - Phone:910-423-2800
Practice Address - Fax:910-423-2800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2013-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-026-823320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7806025Medicaid