MEDICARE: MY BROTHERS HOUSE INC.

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	323P00000X	Psychiatric Residential Treatment Facility	060467	NC

General Provider Information

NPI Number	:	1063606861
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MY BROTHERS HOUSE INC.

Provider Business Mailing Address
First Line	:	4822 ALBEMARLE RD STE 105
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28205-6612
Country	:	US
Telephone Number	:	704-532-4770
Fax Number	:

Provider Business Practice Location Address
First Line	:	8525 WOOFFORD BRIDGE DRIVE
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28216-6612
Country	:	US
Telephone Number	:	704-532-4770
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	RICHARD TAYLOR
Credential	:
Telephone Number	:	704-532-4770

Provider Enumeration Date	:	09/05/2007
Last Update Date	:	09/05/2007

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Directions to “MY BROTHERS HOUSE INC. ” Practice Location

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