MEDICARE: CHRISTOPHER'S KINGDOM 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		NC

General Provider Information

NPI Number	:	1578742490
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHRISTOPHER'S KINGDOM INC.

Provider Business Mailing Address
First Line	:	5703 BEACH WATER DR
Second Line	:	#103
City	:	RALEIGH
State	:	NC
Zip	:	27604-8712
Country	:	US
Telephone Number	:	919-266-6969
Fax Number	:	919-266-6969

Provider Business Practice Location Address
First Line	:	5703 BEACH WATER DR
Second Line	:	#103
City	:	RALEIGH
State	:	NC
Zip	:	27604-8712
Country	:	US
Telephone Number	:	919-266-6969
Fax Number	:	919-266-6969

Authorized Official
Title or Position	:	FACILITY DIRECTOR
Name	:	MRS. CICLEY RENEE MALONE
Credential	:
Telephone Number	:	919-522-9674

Provider Enumeration Date	:	10/26/2007
Last Update Date	:	12/27/2007

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