Provider Demographics
NPI:1891116562
Name:MY BROTHER'S KEEPER OF WAYNE COUNTY, LLC
Entity Type:Organization
Organization Name:MY BROTHER'S KEEPER OF WAYNE COUNTY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/QUALIFIED PROFESSIONAL
Authorized Official - Prefix:MS
Authorized Official - First Name:MARLENA
Authorized Official - Middle Name:
Authorized Official - Last Name:COX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-731-4455
Mailing Address - Street 1:200 W ASH ST
Mailing Address - Street 2:STE 109
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27530-3662
Mailing Address - Country:US
Mailing Address - Phone:919-731-4455
Mailing Address - Fax:
Practice Address - Street 1:200 W ASH ST
Practice Address - Street 2:STE 109
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27530-3662
Practice Address - Country:US
Practice Address - Phone:919-731-4455
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-26
Last Update Date:2013-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management