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General NPI Number Information
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NPI Number | 1164772489
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Entity Type | Organization
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Legal Business Name | PITT COUNTY GROUP HOME BOARD FOR MENTALLY RETARDED, AUTISTIC PERSONS,
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Dates
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Enumeration Date | 09/13/2012
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Last Update Date | 09/13/2012
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Provider Practice Location Address
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Address Line | 2240 EDGEWATER DR
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City | WINTERVILLE
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State | NC
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Zip | 28590-9601
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Country | US
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Telephone | 252-524-4950
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Fax | 252-524-3870
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Provider Business Mailing Address
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Address Line | PO BOX 9
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City | GRIFTON
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State | NC
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Zip | 28530-0009
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Country | US
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Telephone | 252-524-4950
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Fax | 252-524-3870
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MARY GRACE BRIGHT
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Credential |
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Telephone | 252-524-4950
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320600000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
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License Number | MHL-074-037
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License Number State | NC
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