NPIMap

Organization Active NPI

Pelham Supportive Services

  • Mental Illness Community Based Residential Treatment Facility
  • Fayetteville, NC
National Provider Identifier
1770924482
Registry record updated Jul 11, 2013
On this page

Key facts

NPPES NPI Registry
Primary specialty
Mental Illness Community Based Residential Treatment FacilityTaxonomy code 320800000X
License
MHL-026-854 Issued in NC
Legal business name
PELHAM SUPPORTIVE SERVICES
Doing business as
PELHAM GROUP HOME #3
Practice address
5740 Longview Dr
Fayetteville, NC 28306-8567
Phone
(910) 425-4168
Fax
(910) 488-8823
NPI assigned
Jul 10, 2013
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 11, 2013

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mildred Wilson
Title
Director
Phone
(910) 488-7633

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Mental Illness Community Based Residential Treatment Facility 320800000X MHL-026-854 NC Primary

Addresses

Primary practice location

5740 Longview Dr
Fayetteville, NC 28306-8567

Mailing address

949 Country Club Dr
Fayetteville, NC 28301-2907
Phone (910) 488-7633

Other identifiers 1

IdentifierTypeStateIssuer
7806041MedicaidNC

Other names 1

  • PELHAM GROUP HOME #3 Doing business as

National Provider Directory

National Provider Directory
Tax ID family
Pelham Supportive Services6 organizations share this tax ID, including this one

Other organizations with this tax ID 5

Organizations that report the same tax identification number in the National Provider Directory.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1373414400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1373500800000",
    "number": "1770924482",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "949 COUNTRY CLUB DR",
            "city": "FAYETTEVILLE",
            "state": "NC",
            "postal_code": "283012907",
            "telephone_number": "910-488-7633"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5740 LONGVIEW DR",
            "city": "FAYETTEVILLE",
            "state": "NC",
            "postal_code": "283068567",
            "telephone_number": "910-425-4168",
            "fax_number": "910-488-8823"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PELHAM SUPPORTIVE SERVICES",
        "organizational_subpart": "NO",
        "enumeration_date": "2013-07-10",
        "last_updated": "2013-07-11",
        "status": "A",
        "authorized_official_last_name": "WILSON",
        "authorized_official_first_name": "MILDRED",
        "authorized_official_title_or_position": "DIRECTOR",
        "authorized_official_telephone_number": "910-488-7633"
    },
    "taxonomies": [
        {
            "code": "320800000X",
            "taxonomy_group": "",
            "desc": "Community Based Residential Treatment Facility, Mental Illness",
            "state": "NC",
            "license": "MHL-026-854",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7806041",
            "state": "NC"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "PELHAM GROUP HOME #3",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Fayetteville, NC

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 11, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.