Provider Demographics
NPI:1588760433
Name:LEE COUNTY GROUP HOME, INC.
Entity type:Organization
Organization Name:LEE COUNTY GROUP HOME, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:GENERAL BOARD FINANCIAL
Authorized Official - Prefix:
Authorized Official - First Name:JUDIETH
Authorized Official - Middle Name:
Authorized Official - Last Name:AUTRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-770-5484
Mailing Address - Street 1:PO BOX 1373
Mailing Address - Street 2:LEE # 2
Mailing Address - City:SANFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27331-1373
Mailing Address - Country:US
Mailing Address - Phone:919-776-9189
Mailing Address - Fax:919-774-7711
Practice Address - Street 1:2412 KNOLLWOOD DR
Practice Address - Street 2:LEE # 2
Practice Address - City:SANFORD
Practice Address - State:NC
Practice Address - Zip Code:27330-7671
Practice Address - Country:US
Practice Address - Phone:919-776-9189
Practice Address - Fax:919-774-7711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2025-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL053041320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC780514Medicaid
NC295121Medicare ID - Type Unspecified