MEDICARE: BAPTIST CAMP ROAD 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	310400000X	Assisted Living Facility	MHL 012-067	NC

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	:	1962522987
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BAPTIST CAMP ROAD GROUP HOME

Provider Business Mailing Address
First Line	:	4015 BAPTIST CAMP RD
Second Line	:
City	:	CONNELLY SPRINGS
State	:	NC
Zip	:	28612-8263
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4015 BAPTIST CAMP RD
Second Line	:
City	:	CONNELLYS SPRINGS
State	:	NC
Zip	:	28612-8263
Country	:	US
Telephone Number	:	828-437-0807
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JUDY FISHER
Credential	:
Telephone Number	:	828-437-0807

Provider Enumeration Date	:	03/31/2007
Last Update Date	:	08/22/2020

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