Healthcare Provider Details

I. General information

NPI: 1114069119
Provider Name (Legal Business Name): MY BROTHERS HOUSE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 07/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4822 ALBEMARLE RD STE 105
CHARLOTTE NC
28205-6612
US

IV. Provider business mailing address

4822 ALBEMARLE RD SUITE 105
CHARLOTTE NC
28205-6668
US

V. Phone/Fax

Practice location:
  • Phone: 704-532-4770
  • Fax: 704-532-4774
Mailing address:
  • Phone: 704-532-4770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number060-757
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number060-538
License Number StateNC
# 5
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number060-467
License Number StateNC
# 6
Primary TaxonomyY
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number092-519
License Number StateNC

VIII. Authorized Official

Name: MR. RICHARD TAYLOR
Title or Position: CEO
Credential:
Phone: 704-532-4770