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General NPI Number Information
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NPI Number | 1194814038
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Entity Type | Organization
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Legal Business Name | NEW LIFE COMMUNITY GROUP HOME, INC.
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Dates
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Enumeration Date | 10/11/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 2885 MARSHALLBERG STREET
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City | WINSTON-SALEM
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State | NC
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Zip | 27105
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Country | US
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Telephone | 336-595-4501
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Fax |
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Provider Business Mailing Address
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Address Line | 2885 MARSHALLBERG STREET
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City | WINSTON-SALEM
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State | NC
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Zip | 27105
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | BEATRICE D HARDEE
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Credential |
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Telephone | 336-595-4501
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320900000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
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License Number | MHL-034-202
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License Number State | NC
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