Healthcare Provider Details

I. General information

NPI: 1861533853
Provider Name (Legal Business Name): MAG'S HOUSE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7638 JACKSON SCHOOL RD # A
BROWNS SUMMIT NC
27214-9706
US

IV. Provider business mailing address

5214 BUNCH RD
SUMMERFIELD NC
27358-9138
US

V. Phone/Fax

Practice location:
  • Phone: 336-656-5336
  • Fax: 336-643-9189
Mailing address:
  • Phone: 336-656-5336
  • Fax: 336-643-9189

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License NumberMHL-041-802
License Number StateNC

VIII. Authorized Official

Name: MS. CYDNEY L BAKER
Title or Position: OWNER
Credential:
Phone: 336-558-8628