MEDICARE: BROTHERS COMMUNITY RESOURCES

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	252Y00000X	Early Intervention Provider Agency
2	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1952539850
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BROTHERS COMMUNITY RESOURCES

Provider Business Mailing Address
First Line	:	2556 MINT JULEP DR
Second Line	:
City	:	CREEDMOOR
State	:	NC
Zip	:	27522-7817
Country	:	US
Telephone Number	:	919-528-4900
Fax Number	:	919-528-1234

Provider Business Practice Location Address
First Line	:	106 W CHURCH ST STE B
Second Line	:
City	:	CREEDMOOR
State	:	NC
Zip	:	27522-9765
Country	:	US
Telephone Number	:	919-528-4900
Fax Number	:	919-528-1234

Authorized Official
Title or Position	:	OWNER
Name	:	CLARENCE MARCELLUS
Credential	:
Telephone Number	:	919-528-4900

Provider Enumeration Date	:	06/30/2009
Last Update Date	:	06/30/2009

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