MEDICARE: GREAT ACCOMPLISHMENTS 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	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility	MHL-024071	NC

General Provider Information

NPI Number	:	1326215781
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREAT ACCOMPLISHMENTS INC.

Provider Business Mailing Address
First Line	:	230 CRABAPPLE LN
Second Line	:
City	:	LAKE WACCAMAW
State	:	NC
Zip	:	28450-9594
Country	:	US
Telephone Number	:	910-354-0679
Fax Number	:

Provider Business Practice Location Address
First Line	:	230 CRABAPPLE LN
Second Line	:
City	:	LAKE WACCAMAW
State	:	NC
Zip	:	28450-9594
Country	:	US
Telephone Number	:	910-354-0679
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF OPERATIONS
Name	:	MRS. TONYA LARICE CLARK-BAEZ
Credential	:
Telephone Number	:	910-354-0679

Provider Enumeration Date	:	05/14/2008
Last Update Date	:	05/14/2008

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