Healthcare Provider Details

I. General information

NPI: 1821117839
Provider Name (Legal Business Name): MITCHELL COUNTY GROUP HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 03/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

86 RICHMOND RD
BAKERSVILLE NC
28705-9460
US

IV. Provider business mailing address

86 RICHMOND RD
BAKERSVILLE NC
28705-9460
US

V. Phone/Fax

Practice location:
  • Phone: 828-688-2521
  • Fax: 828-688-2521
Mailing address:
  • Phone: 828-688-2521
  • Fax: 828-688-2521

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License NumberMHL-061-008
License Number StateNC

VIII. Authorized Official

Name: CECELIA B GREEN
Title or Position: EXECUTIVE DIRECTOR
Credential: B.S.
Phone: 828-688-2521