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General NPI Number Information
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NPI Number | 1538234372
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Entity Type | Organization
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Legal Business Name | 1ST & 10 GROUP HOME INC
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Dates
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Enumeration Date | 11/21/2006
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Last Update Date | 03/28/2008
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Provider Practice Location Address
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Address Line | 206 NORTH EAST STREET
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City | ROSEBORE
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State | NC
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Zip | 28382-1353
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Country | US
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Telephone | 910-525-5488
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Fax | 910-525-5433
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Provider Business Mailing Address
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Address Line | PO BOX 41
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City | CLINTON
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State | NC
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Zip | 28329-0041
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Country | US
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Telephone | 910-299-0096
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Fax | 910-299-0010
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. JERRIS CORNELIUS MCPHAIL
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Credential |
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Telephone | 910-299-0099
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 322D00000X
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Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
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License Number | MHL082059
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License Number State | NC
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