MEDICARE: GRANDFATHER HOME - RALEIGH

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	320800000X	Mental Illness Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1629251293
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRANDFATHER HOME - RALEIGH

Provider Business Mailing Address
First Line	:	PO BOX 98
Second Line	:
City	:	BANNER ELK
State	:	NC
Zip	:	28604-0098
Country	:	US
Telephone Number	:	828-898-5465
Fax Number	:	828-898-6140

Provider Business Practice Location Address
First Line	:	5000 HOLLY RIDGE FARM RD
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27616-6121
Country	:	US
Telephone Number	:	828-898-5465
Fax Number	:	828-898-6140

Authorized Official
Title or Position	:	CEO
Name	:	MR. JIM SWINKOLA
Credential	:	MBA
Telephone Number	:	828-898-5465

Provider Enumeration Date	:	12/06/2007
Last Update Date	:	08/08/2008

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Directions to “GRANDFATHER HOME - RALEIGH ” Practice Location

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