MEDICARE: MY FRIEND'S HOUSE, LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	320800000X	Mental Illness Community Based Residential Treatment Facility
2	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility
3	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1164662466
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MY FRIEND'S HOUSE, LLC

Provider Business Mailing Address
First Line	:	3607 COLUMBIA AVENUE
Second Line	:
City	:	WILSON
State	:	NC
Zip	:	27896
Country	:	US
Telephone Number	:	252-206-7408
Fax Number	:	312-324-0677

Provider Business Practice Location Address
First Line	:	3607 COLUMBIA AVENUE
Second Line	:
City	:	WILSON
State	:	NC
Zip	:	27896
Country	:	US
Telephone Number	:	252-206-7408
Fax Number	:	312-324-0677

Authorized Official
Title or Position	:	OWNER/MEMBER
Name	:	MS. CONNIE BUTTERFIELD
Credential	:
Telephone Number	:	252-206-7408

Provider Enumeration Date	:	02/26/2009
Last Update Date	:	02/26/2009

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Directions to “MY FRIEND'S HOUSE, LLC ” Practice Location

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