Provider Demographics
NPI:1215127675
Name:1ST & 10 GROUP HOME, INC. #2
Entity type:Organization
Organization Name:1ST & 10 GROUP HOME, INC. #2
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRIS
Authorized Official - Middle Name:CORNELIUS
Authorized Official - Last Name:MCPHAIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-299-0099
Mailing Address - Street 1:PO BOX 41
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:NC
Mailing Address - Zip Code:28329-0041
Mailing Address - Country:US
Mailing Address - Phone:910-299-0099
Mailing Address - Fax:910-299-0010
Practice Address - Street 1:6090 TURKEY HIGHWAY
Practice Address - Street 2:
Practice Address - City:TURKEY
Practice Address - State:NC
Practice Address - Zip Code:28393-9998
Practice Address - Country:US
Practice Address - Phone:910-590-2034
Practice Address - Fax:910-299-0010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-31
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL082071322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6604227Medicaid