MEDICARE: CYRUS HOME LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility	MHL092262	NC

General Provider Information

NPI Number	:	1043641830
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CYRUS HOME LLC

Provider Business Mailing Address
First Line	:	3101 GINGER LAKE CT
Second Line	:
City	:	ZEBULON
State	:	NC
Zip	:	27597-5738
Country	:	US
Telephone Number	:	919-217-0015
Fax Number	:	919-404-8252

Provider Business Practice Location Address
First Line	:	3101 GINGER LAKE CT
Second Line	:
City	:	ZEBULON
State	:	NC
Zip	:	27597-5738
Country	:	US
Telephone Number	:	919-217-0015
Fax Number	:	919-404-8252

Authorized Official
Title or Position	:	OWNER/OPERATOR
Name	:	MRS. LUEASE CYRUS
Credential	:
Telephone Number	:	919-217-0015

Provider Enumeration Date	:	12/05/2013
Last Update Date	:	07/21/2022

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