=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104013994
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEARLS FAMILY CARE HOME #3
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2007
-----------------------------------------------------
Last Update Date | 07/25/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 105 ASH CT
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28546-8503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-938-0251
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 674 SMITH RD
-----------------------------------------------------
City | MAYSVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28555-9120
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-326-3526
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADM
-----------------------------------------------------
Name | PEARLIE M BERRY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 910-326-3526
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320800000X
-----------------------------------------------------
Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
-----------------------------------------------------
License Number | 067009
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------