Healthcare Provider Details

I. General information

NPI: 1679939896
Provider Name (Legal Business Name): AMAT GROUP HOMES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2016
Last Update Date: 02/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

906 E PROSPECT AVE
RAEFORD NC
28376-2328
US

IV. Provider business mailing address

5515 PLAIN VIEW HWY
DUNN NC
28334-6843
US

V. Phone/Fax

Practice location:
  • Phone: 910-595-2910
  • Fax:
Mailing address:
  • Phone: 910-922-9583
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberMHL-047-160
License Number StateNC

VIII. Authorized Official

Name: IBILOLA ARIDEGBE
Title or Position: PRESIDENT
Credential:
Phone: 910-922-9583