MEDICARE: JIREH'S PLACE, 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	251S00000X	Community/Behavioral Health Agency

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	:	1750418273
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JIREH'S PLACE, INC.

Provider Business Mailing Address
First Line	:	5128 ROSEMEDE DR
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28227-3011
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5128 ROSEMEDE DR
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28227-3011
Country	:	US
Telephone Number	:	704-535-5590
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. EDWARD PHILLIP VANDERSHORST
Credential	:
Telephone Number	:	704-535-5590

Provider Enumeration Date	:	02/28/2007
Last Update Date	:	08/22/2020

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Directions to “JIREH'S PLACE, INC. ” Practice Location

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