Healthcare Provider Details

I. General information

NPI: 1821159278
Provider Name (Legal Business Name): BENJAMIN HOUSE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 03/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

848 FOREST PARK ROAD
ELIZABETH CITY NC
27909-5461
US

IV. Provider business mailing address

PO BOX 757
ELIZABETH CITY NC
27907-0757
US

V. Phone/Fax

Practice location:
  • Phone: 252-331-7731
  • Fax: 252-331-1777
Mailing address:
  • Phone: 252-331-7731
  • Fax: 252-331-1777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number3408242
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberMHL-070-039
License Number StateNC

VIII. Authorized Official

Name: MRS. JAYNE JONES HOLLOWELL
Title or Position: DIRECTOR
Credential: BA
Phone: 252-331-7731