Provider Demographics
NPI:1700065224
Name:MCG DIVERSIFIED, LLC
Entity Type:Organization
Organization Name:MCG DIVERSIFIED, LLC
Other - Org Name:H.O.P.E
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BOBBY
Authorized Official - Middle Name:E
Authorized Official - Last Name:MCGUIRE
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:252-883-9329
Mailing Address - Street 1:809 MILL BRANCH RD
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27803-8512
Mailing Address - Country:US
Mailing Address - Phone:252-446-6243
Mailing Address - Fax:252-446-6244
Practice Address - Street 1:809 MILL BRANCH RD
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27803-8512
Practice Address - Country:US
Practice Address - Phone:252-446-6243
Practice Address - Fax:252-446-6244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-31
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization