MEDICARE: WILLIAMS GROUP HOME, 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	MHL071-020	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1396805735
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILLIAMS GROUP HOME, INC.

Provider Business Mailing Address
First Line	:	PO BOX 696
Second Line	:
City	:	BURGAW
State	:	NC
Zip	:	28425-0696
Country	:	US
Telephone Number	:	910-259-7677
Fax Number	:	910-259-6009

Provider Business Practice Location Address
First Line	:	2161 NEW RD
Second Line	:
City	:	BURGAW
State	:	NC
Zip	:	28425-3143
Country	:	US
Telephone Number	:	910-259-7677
Fax Number	:	910-259-6009

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MRS. AMY MONROE
Credential	:	BACHELOR OF ARTS
Telephone Number	:	910-259-7677

Provider Enumeration Date	:	12/08/2006
Last Update Date	:	08/22/2020

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