Healthcare Provider Details

I. General information

NPI: 1407697865
Provider Name (Legal Business Name): BROTHERS CARE GROUP HOMES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2024
Last Update Date: 06/04/2024
Certification Date: 06/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 BEAUHAVEN LN
WAXHAW NC
28173-7451
US

IV. Provider business mailing address

611 BEAUHAVEN LN
WAXHAW NC
28173-7451
US

V. Phone/Fax

Practice location:
  • Phone: 617-877-1429
  • Fax:
Mailing address:
  • Phone: 617-877-1429
  • 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
# 2
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: KEL DELPHINE NJIKE TAH
Title or Position: MANAGER
Credential:
Phone: 617-877-1429