Provider Demographics
NPI:1750104246
Name:BLUE GROUP HOME LLC
Entity type:Organization
Organization Name:BLUE GROUP HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:TINA
Authorized Official - Middle Name:R
Authorized Official - Last Name:MEBANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-456-2370
Mailing Address - Street 1:PO BOX 5016
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27435-0016
Mailing Address - Country:US
Mailing Address - Phone:336-456-2370
Mailing Address - Fax:336-763-5065
Practice Address - Street 1:2722 N CHURCH ST STE D
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-3661
Practice Address - Country:US
Practice Address - Phone:336-456-2370
Practice Address - Fax:336-763-5065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-04
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health