Organization
PELHAM SUPPORTIVE SERVICES
Active
Other names
PELHAM GROUP HOME #1
Organization subpart
No
Provider details
NPI number
Authorized official
MILDRED WILSON (OWNER)
(910) 630-6757
Entity
Organization
Contact information
Practice address
1712 SHILOH DR, FAYETTEVILLE, NC 28304-4027
(910) 423-2800
(910) 423-2800
Mailing address
949 COUNTRY CLUB DR, FAYETTEVILLE, NC 28301-2907
(910) 630-6757
(910) 884-9806
Taxonomy
Speciality
Code
Description
License number
State
320800000X
Mental Illness Community Based Residential Treatment Facility
Primary
MHL-026-823
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
7806025
—
NC
Enumeration date
12/15/2006
Last updated
07/10/2013
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