Church Street Group Home LLC

Primary specialty

Assisted Living Facility (Mental Illness)Taxonomy code 3104A0625X

License

MHL-001-213 Issued in NC

Legal business name

CHURCH STREET GROUP HOME LLC

Practice address

1017 S Church St
Burlington, NC 27215-5045

Phone

(336) 227-1613

Fax

(336) 227-1613

NPI assigned

Apr 27, 2011

Organization subpart

No

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

Authorized official

Name

Ms. Mittie B Fuller

Title

President/Owner

Phone

(336) 227-1613

Specialties & licenses 1

Addresses

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

{
    "created_epoch": "1303862400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1303862400000",
    "number": "1821389776",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1996",
            "city": "BURLINGTON",
            "state": "NC",
            "postal_code": "272161996",
            "telephone_number": "336-227-1613",
            "fax_number": "336-227-1613"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1017 S CHURCH ST",
            "city": "BURLINGTON",
            "state": "NC",
            "postal_code": "272155045",
            "telephone_number": "336-227-1613",
            "fax_number": "336-227-1613"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CHURCH STREET GROUP HOME LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-04-27",
        "last_updated": "2011-04-27",
        "status": "A",
        "authorized_official_last_name": "FULLER",
        "authorized_official_first_name": "MITTIE",
        "authorized_official_middle_name": "B",
        "authorized_official_title_or_position": "PRESIDENT/OWNER",
        "authorized_official_telephone_number": "336-227-1613",
        "authorized_official_name_prefix": "Ms."
    },
    "taxonomies": [
        {
            "code": "3104A0625X",
            "taxonomy_group": "",
            "desc": "Assisted Living Facility, Assisted Living, Mental Illness",
            "state": "NC",
            "license": "MHL-001-213",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Benjamin Lee Clapp

• Assisted Living Facility (Mental Illness) in Burlington, NC
• Providers in Burlington, NC by specialty
• Assisted Living Facility (Mental Illness) in North Carolina

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 27, 2011; 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.