MEDICARE: PROSPEROUS LIVING ADOLESCENT CENTER, 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	320800000X	Mental Illness Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1295971844
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROSPEROUS LIVING ADOLESCENT CENTER, INC

Provider Business Mailing Address
First Line	:	3412 LAKE WOODARD DR
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27604-3854
Country	:	US
Telephone Number	:	919-231-0025
Fax Number	:

Provider Business Practice Location Address
First Line	:	3412 LAKE WOODARD DR
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27604-3854
Country	:	US
Telephone Number	:	919-231-0025
Fax Number	:

Authorized Official
Title or Position	:	PROGRAM DIRECTOR
Name	:	MRS. MILDRED M BROWN
Credential	:
Telephone Number	:	919-361-0208

Provider Enumeration Date	:	01/04/2009
Last Update Date	:	12/30/2016

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