=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700062205
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAWRENCE EDWARD GRAHAM JR YOUTH OUTREACH FACILITY, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/14/2008
-----------------------------------------------------
Last Update Date | 01/14/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9431 NC HIGHWAY 211 W
-----------------------------------------------------
City | RED SPRINGS
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28377-6001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-843-5976
-----------------------------------------------------
Fax | 910-843-5976
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1952
-----------------------------------------------------
City | RAEFORD
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28376-3952
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-843-5976
-----------------------------------------------------
Fax | 910-843-5976
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER, PRESIDENT, CEO
-----------------------------------------------------
Name | MRS. RONDLA GRAHAM PHILLIP
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 910-964-5034
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320800000X
-----------------------------------------------------
Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
-----------------------------------------------------
License Number | MHL-078-201
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------