MEDICARE: 1ST & 10 GROUP HOME 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	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility	MHL082059	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1538234372
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	1ST & 10 GROUP HOME INC

Provider Business Mailing Address
First Line	:	PO BOX 41
Second Line	:
City	:	CLINTON
State	:	NC
Zip	:	28329-0041
Country	:	US
Telephone Number	:	910-299-0096
Fax Number	:	910-299-0010

Provider Business Practice Location Address
First Line	:	206 NORTH EAST STREET
Second Line	:
City	:	ROSEBORE
State	:	NC
Zip	:	28382-1353
Country	:	US
Telephone Number	:	910-525-5488
Fax Number	:	910-525-5433

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. JERRIS CORNELIUS MCPHAIL
Credential	:
Telephone Number	:	910-299-0099

Provider Enumeration Date	:	11/21/2006
Last Update Date	:	03/28/2008

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