MEDICARE: SPECIAL JEWEL GROUP HOME

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	MHL064102	NC

General Provider Information

NPI Number	:	1730319773
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPECIAL JEWEL GROUP HOME

Provider Business Mailing Address
First Line	:	232 REGENCY DR
Second Line	:
City	:	NASHVILLE
State	:	NC
Zip	:	27856-1812
Country	:	US
Telephone Number	:	252-446-6612
Fax Number	:

Provider Business Practice Location Address
First Line	:	200 S TILLERY ST
Second Line	:
City	:	ROCKY MOUNT
State	:	NC
Zip	:	27804-5527
Country	:	US
Telephone Number	:	252-446-6612
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ALICE CLARK
Credential	:
Telephone Number	:	252-446-6612

Provider Enumeration Date	:	07/24/2009
Last Update Date	:	07/24/2009

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Directions to “SPECIAL JEWEL GROUP HOME ” Practice Location

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