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General NPI Number Information
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NPI Number | 1063606861
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Entity Type | Organization
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Legal Business Name | MY BROTHERS HOUSE INC.
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Dates
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Enumeration Date | 09/05/2007
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Last Update Date | 09/05/2007
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Provider Practice Location Address
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Address Line | 8525 WOOFFORD BRIDGE DRIVE
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City | CHARLOTTE
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State | NC
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Zip | 28216-6612
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Country | US
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Telephone | 704-532-4770
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Fax |
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Provider Business Mailing Address
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Address Line | 4822 ALBEMARLE RD STE 105
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City | CHARLOTTE
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State | NC
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Zip | 28205-6612
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Country | US
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Telephone | 704-532-4770
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | RICHARD TAYLOR
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Credential |
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Telephone | 704-532-4770
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 323P00000X
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Taxonomy Name | Psychiatric Residential Treatment Facility
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License Number | 060467
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License Number State | NC
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