MEDICARE: COMMUNITY OUTREACH GROUP, LLC

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

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	:	1760659254
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMUNITY OUTREACH GROUP, LLC

Provider Business Mailing Address
First Line	:	PO BOX 304
Second Line	:
City	:	WADESBORO
State	:	NC
Zip	:	28170-0304
Country	:	US
Telephone Number	:	919-539-3659
Fax Number	:	704-943-0861

Provider Business Practice Location Address
First Line	:	3600 N DUKE ST
Second Line	:
City	:	DURHAM
State	:	NC
Zip	:	27704-1709
Country	:	US
Telephone Number	:	919-539-3659
Fax Number	:	704-943-0861

Authorized Official
Title or Position	:	MEMBER
Name	:	FASHENDA L LITTLE
Credential	:
Telephone Number	:	919-539-3659

Provider Enumeration Date	:	05/13/2008
Last Update Date	:	05/13/2008

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