MEDICARE: SAMANTHA'S 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	324500000X	Substance Abuse Rehabilitation Facility

General Provider Information

NPI Number	:	1558804468
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAMANTHA'S HOUSE INC.

Provider Business Mailing Address
First Line	:	5412 CREEK RUN CT
Second Line	:
City	:	KINGS MOUNTAIN
State	:	NC
Zip	:	28086-8490
Country	:	US
Telephone Number	:	240-300-2134
Fax Number	:

Provider Business Practice Location Address
First Line	:	5412 CREEK RUN CT
Second Line	:
City	:	KINGS MOUNTAIN
State	:	NC
Zip	:	28086-8490
Country	:	US
Telephone Number	:	240-300-2134
Fax Number	:

Authorized Official
Title or Position	:	CEO/PRESIDENT
Name	:	CORNELL DEWAYNE THOMAS
Credential	:
Telephone Number	:	240-300-2134

Provider Enumeration Date	:	11/24/2016
Last Update Date	:	11/24/2016

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