=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992913396
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MURPHY'S OUTREACH COMMUNITY DEVELOPMENTAL SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/18/2007
-----------------------------------------------------
Last Update Date | 08/20/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 210 E 2ND ST SUITE 125
-----------------------------------------------------
City | LUMBERTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28358-5620
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-738-6767
-----------------------------------------------------
Fax | 910-345-8917
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 210 E 2ND ST SUITE 125
-----------------------------------------------------
City | LUMBERTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28358-5620
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-738-6767
-----------------------------------------------------
Fax | 910-345-8917
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF OPERATIONS
-----------------------------------------------------
Name | MR. DONTA BLACKWELL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 910-738-6767
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | HC2018
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------