MEDICARE: PITT COUNTY GROUP HOME BOARD FOR MENTALLY RETARDED, AUTISTIC PERSONS,

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	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility	MHL074003	NC
2	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility	MHL074015	NC
3	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility	MHL074097	NC
4	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility	MHL074037	NC
5	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility	MHL074021	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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1841315132
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PITT COUNTY GROUP HOME BOARD FOR MENTALLY RETARDED, AUTISTIC PERSONS,

Provider Business Mailing Address
First Line	:	PO BOX 9
Second Line	:
City	:	GRIFTON
State	:	NC
Zip	:	28530-0009
Country	:	US
Telephone Number	:	252-524-4950
Fax Number	:	252-524-3870

Provider Business Practice Location Address
First Line	:	560 WEST QUEEN ST.
Second Line	:
City	:	GRIFTON
State	:	NC
Zip	:	28530-0009
Country	:	US
Telephone Number	:	252-524-4950
Fax Number	:	252-524-3870

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MS. MARY GRACE BRIGHT
Credential	:
Telephone Number	:	252-524-4950

Provider Enumeration Date	:	03/19/2007
Last Update Date	:	08/22/2020

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