Provider Demographics
NPI:1700062205
Name:LAWRENCE EDWARD GRAHAM JR YOUTH OUTREACH FACILITY, INC
Entity Type:Organization
Organization Name:LAWRENCE EDWARD GRAHAM JR YOUTH OUTREACH FACILITY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PRESIDENT, CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:RONDLA
Authorized Official - Middle Name:GRAHAM
Authorized Official - Last Name:PHILLIP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-964-5034
Mailing Address - Street 1:PO BOX 1952
Mailing Address - Street 2:
Mailing Address - City:RAEFORD
Mailing Address - State:NC
Mailing Address - Zip Code:28376-3952
Mailing Address - Country:US
Mailing Address - Phone:910-843-5976
Mailing Address - Fax:910-843-5976
Practice Address - Street 1:9431 NC HIGHWAY 211 W
Practice Address - Street 2:
Practice Address - City:RED SPRINGS
Practice Address - State:NC
Practice Address - Zip Code:28377-6001
Practice Address - Country:US
Practice Address - Phone:910-843-5976
Practice Address - Fax:910-843-5976
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-14
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-078-201320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness