Healthcare Provider Details

I. General information

NPI: 1104010677
Provider Name (Legal Business Name): WELCOME HOME GROUP HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2007
Last Update Date: 07/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 WEST MOUNT DR
ROCKY MT NC
27803-3107
US

IV. Provider business mailing address

1400 WEST MOUNT DR
ROCKY MOUNT NC
27803-3107
US

V. Phone/Fax

Practice location:
  • Phone: 252-443-0593
  • Fax:
Mailing address:
  • Phone: 252-443-0593
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberMHL064085
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License NumberMHL064085
License Number StateNC

VIII. Authorized Official

Name: STACY VEE FARROW
Title or Position: ADMINISTRATOR
Credential:
Phone: 252-443-0593