Healthcare Provider Details

I. General information

NPI: 1750104246
Provider Name (Legal Business Name): BLUE GROUP HOME LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2024
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8450 ALLEGRA TRCE
BROWNS SUMMIT NC
27214-9894
US

IV. Provider business mailing address

PO BOX 5016
GREENSBORO NC
27435-0016
US

V. Phone/Fax

Practice location:
  • Phone: 336-456-2370
  • Fax: 336-763-5065
Mailing address:
  • Phone: 336-456-2370
  • Fax: 336-763-5065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: TINA ROCHELL MEBANE
Title or Position: OWNER
Credential:
Phone: 336-456-2370