=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245360387
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EDWARDS GROUP HOME 3
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2007
-----------------------------------------------------
Last Update Date | 01/10/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1233 APPLETREE ROAD
-----------------------------------------------------
City | STANTONSBURG
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27833
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-747-4000
-----------------------------------------------------
Fax | 252-747-2602
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 295
-----------------------------------------------------
City | SNOW HILL
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28580-0295
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-747-4000
-----------------------------------------------------
Fax | 252-747-2602
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | THOMAS MCCOLLUM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 252-747-4000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320800000X
-----------------------------------------------------
Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
-----------------------------------------------------
License Number | MHL040026
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------