MEDICARE: TAR HEEL HABILITATION SERVICES LLC

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	251C00000X	Developmentally Disabled Services Day Training Agency	MHL-080-175	NC

General Provider Information

NPI Number	:	1891946182
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TAR HEEL HABILITATION SERVICES LLC

Provider Business Mailing Address
First Line	:	512 KLUMAC RD
Second Line	:	SUITE #2
City	:	SALISBURY
State	:	NC
Zip	:	28144-6758
Country	:	US
Telephone Number	:	704-431-4649
Fax Number	:

Provider Business Practice Location Address
First Line	:	512 KLUMAC RD
Second Line	:	SUITE #2
City	:	SALISBURY
State	:	NC
Zip	:	28144-6758
Country	:	US
Telephone Number	:	704-431-4649
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. ANDRE PAUL GASTON
Credential	:	J.D.
Telephone Number	:	704-431-4649

Provider Enumeration Date	:	10/04/2008
Last Update Date	:	10/04/2008

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