MEDICARE: BOYS & GIRLS HOMES OF NC, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency	B00004	NC
2	253J00000X	Foster Care Agency	B00004	NC

General Provider Information

NPI Number	:	1245542745
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOYS & GIRLS HOMES OF NC, INC

Provider Business Mailing Address
First Line	:	PO BOX 127
Second Line	:
City	:	LAKE WACCAMAW
State	:	NC
Zip	:	28450-0127
Country	:	US
Telephone Number	:	910-646-3083
Fax Number	:	910-646-1232

Provider Business Practice Location Address
First Line	:	104 E OLD HIGHWAY 74 76
Second Line	:
City	:	LAKE WACCAMAW
State	:	NC
Zip	:	28450-2512
Country	:	US
Telephone Number	:	910-646-3083
Fax Number	:	910-356-0081

Authorized Official
Title or Position	:	CEO
Name	:	MR. RICKY CREECH
Credential	:
Telephone Number	:	910-646-3083

Provider Enumeration Date	:	07/13/2010
Last Update Date	:	01/31/2022

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