MEDICARE: A PLACE OF THEIR OWN,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	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility	MHL-041-852	NC
2	320800000X	Mental Illness Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1821291493
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	A PLACE OF THEIR OWN,LLC

Provider Business Mailing Address
First Line	:	5629 BURLINGTON RD
Second Line	:	1525 BOWMORE PLACE
City	:	MC LEANSVILLE
State	:	NC
Zip	:	27301-9209
Country	:	US
Telephone Number	:	336-382-0178
Fax Number	:	336-697-7484

Provider Business Practice Location Address
First Line	:	5629 BURLINGTON RD
Second Line	:	1525 BOWMORE PLACE
City	:	MC LEANSVILLE
State	:	NC
Zip	:	27301-9209
Country	:	US
Telephone Number	:	336-382-0178
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MISS CHANISTY H MITCHELL
Credential	:
Telephone Number	:	336-382-0178

Provider Enumeration Date	:	06/08/2007
Last Update Date	:	08/17/2020

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