1538488192 NPI number — KYSEEM'S UNITY GROUP HOME, LLC

Table of content: (NPI 1538488192)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538488192 NPI number — KYSEEM'S UNITY GROUP HOME, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KYSEEM'S UNITY GROUP HOME, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1538488192
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/20/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 129
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PINETOPS
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27864-0129
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
252-902-6277
Provider Business Mailing Address Fax Number:
252-758-1119

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
408 EAST TARBORO STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PINETOPS
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27864-2786
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-902-7078
Provider Business Practice Location Address Fax Number:
252-756-8586
Provider Enumeration Date:
05/21/2010

Additional Information

Authorized Official

Authorized Official Last Name:
POWELL
Authorized Official First Name:
DEARL
Authorized Official Middle Name:
RAY
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
252-902-7078

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  MHL033076 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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