Healthcare Provider Details

I. General information

NPI: 1740517697
Provider Name (Legal Business Name): PELHAM GARDENS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2009
Last Update Date: 11/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 OLD HWY 29
PELHAM NC
27311
US

IV. Provider business mailing address

PO BOX 38551
GREENSBORO NC
27438
US

V. Phone/Fax

Practice location:
  • Phone: 336-210-1446
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. GREGORY VINCENT
Title or Position: OWNER/CEO
Credential:
Phone: 336-210-1446