1750522165 NPI number — PROFESSIONAL GROUP LIVING, LLC

Table of content: (NPI 1750522165)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750522165 NPI number — PROFESSIONAL GROUP LIVING, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROFESSIONAL GROUP LIVING, 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:
1750522165
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/13/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
510 SIMMONS ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DURHAM
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27701-4334
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-688-0818
Provider Business Mailing Address Fax Number:
919-688-0918

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
715 SOUTHWEST BLVD.
Provider Second Line Business Practice Location Address:
B
Provider Business Practice Location Address City Name:
CLINTON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28328-4829
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-592-2338
Provider Business Practice Location Address Fax Number:
919-592-5508
Provider Enumeration Date:
03/13/2009

Additional Information

Authorized Official

Authorized Official Last Name:
HICKS
Authorized Official First Name:
LLEWELLYN
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
919-475-6124

Provider Taxonomy Codes

  • Taxonomy code: 251C00000X , with the licence number:  8109498 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X , with the licence number: 8109498 , 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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