Healthcare Provider Details

I. General information

NPI: 1457736290
Provider Name (Legal Business Name): HOLLY HILLS GROUP HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2015
Last Update Date: 05/20/2022
Certification Date: 05/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

84 HOLLY HILL DR
COLUMBUS NC
28722-6434
US

IV. Provider business mailing address

20 JERVEY RD SUITE 102
TRYON NC
28782-0017
US

V. Phone/Fax

Practice location:
  • Phone: 828-859-0259
  • Fax:
Mailing address:
  • Phone: 828-859-0259
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License NumberMH075023
License Number StateNC

VIII. Authorized Official

Name: JULIE GRIGG
Title or Position: EXECUTIVE ADMINISTRATOR
Credential:
Phone: 828-859-0259