MEDICARE: BYNUM'S PLACE 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	MHL093037	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	031264	OTHER	NC	FACILITY ID

General Provider Information

NPI Number	:	1922140888
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BYNUM'S PLACE LLC

Provider Business Mailing Address
First Line	:	131 BYNUM'S PLACE
Second Line	:
City	:	NORLINA
State	:	NC
Zip	:	27563-9139
Country	:	US
Telephone Number	:	252-257-0149
Fax Number	:	252-257-2307

Provider Business Practice Location Address
First Line	:	131 BYNUM'S PLACE
Second Line	:
City	:	NORLINA
State	:	NC
Zip	:	27563-9139
Country	:	US
Telephone Number	:	252-257-0149
Fax Number	:	252-257-2307

Authorized Official
Title or Position	:	OWNER
Name	:	MOORE BYNUM
Credential	:
Telephone Number	:	252-915-9174

Provider Enumeration Date	:	02/13/2007
Last Update Date	:	08/22/2020

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