MEDICARE: SYLVANGLADE 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	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility	MHL041572	NC

General Provider Information

NPI Number	:	1629273610
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SYLVANGLADE HOME, INC.

Provider Business Mailing Address
First Line	:	4915 SYLVANGLADE RD
Second Line	:
City	:	MC LEANSVILLE
State	:	NC
Zip	:	27301-9753
Country	:	US
Telephone Number	:	336-358-2156
Fax Number	:

Provider Business Practice Location Address
First Line	:	4915 SYLVANGLADE RD
Second Line	:
City	:	MC LEANSVILLE
State	:	NC
Zip	:	27301-9753
Country	:	US
Telephone Number	:	336-358-2156
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MRS. HATTIE CHEEKS GRAVES
Credential	:
Telephone Number	:	336-621-8119

Provider Enumeration Date	:	06/19/2007
Last Update Date	:	08/29/2011

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