Provider Demographics
NPI:1992858872
Name:ST.MARYSGROUPHOMESINC.
Entity Type:Organization
Organization Name:ST.MARYSGROUPHOMESINC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FACILTY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JUMOKA
Authorized Official - Middle Name:AYAANA
Authorized Official - Last Name:MURRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-363-1462
Mailing Address - Street 1:1071 PEMBERTON HILL RD
Mailing Address - Street 2:
Mailing Address - City:APEX
Mailing Address - State:NC
Mailing Address - Zip Code:27502-4268
Mailing Address - Country:US
Mailing Address - Phone:919-363-1462
Mailing Address - Fax:919-367-9474
Practice Address - Street 1:1071 PEMBERTON HILL RD
Practice Address - Street 2:
Practice Address - City:APEX
Practice Address - State:NC
Practice Address - Zip Code:27502-4268
Practice Address - Country:US
Practice Address - Phone:919-363-1462
Practice Address - Fax:919-367-9474
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-096-1723104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7805652Medicaid