Provider Demographics
NPI:1215097357
Name:NC OUTREACH GROUP HOMES, LLC
Entity type:Organization
Organization Name:NC OUTREACH GROUP HOMES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:V
Authorized Official - Last Name:BURLESON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-442-4020
Mailing Address - Street 1:PO BOX 249
Mailing Address - Street 2:
Mailing Address - City:NEBO
Mailing Address - State:NC
Mailing Address - Zip Code:28761-0021
Mailing Address - Country:US
Mailing Address - Phone:828-652-7613
Mailing Address - Fax:828-527-0789
Practice Address - Street 1:252 NC 126
Practice Address - Street 2:
Practice Address - City:NEBO
Practice Address - State:NC
Practice Address - Zip Code:28761-2876
Practice Address - Country:US
Practice Address - Phone:828-559-9940
Practice Address - Fax:828-738-1526
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7805640Medicaid