Provider Demographics
NPI:1285033761
Name:UNIVERSAL GROUP HOME LLC
Entity type:Organization
Organization Name:UNIVERSAL GROUP HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:FAYE
Authorized Official - Last Name:SPRUILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-344-8846
Mailing Address - Street 1:411 FOREST DR
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27534-3323
Mailing Address - Country:US
Mailing Address - Phone:919-344-8846
Mailing Address - Fax:
Practice Address - Street 1:609 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MOUNT OLIVE
Practice Address - State:NC
Practice Address - Zip Code:28365-2248
Practice Address - Country:US
Practice Address - Phone:919-344-8846
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-20
Last Update Date:2014-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-031-075311ZA0620X
NCMHL-096-254311ZA0620X
NCMHL-096-255311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home