Healthcare Provider Details

I. General information

NPI: 1053595546
Provider Name (Legal Business Name): HILLS DDA GROUP HOME INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2007
Last Update Date: 07/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2017 EAST RIDGE CIR
KINSTON NC
28501
US

IV. Provider business mailing address

PO BOX 5425 2017 EAST RIDGE CIRCLE
KINSTON NC
28501
US

V. Phone/Fax

Practice location:
  • Phone: 252-522-4869
  • Fax:
Mailing address:
  • Phone: 252-522-4869
  • Fax: 252-522-4869

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberMHL054111
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. ALICETINE P ROUSE
Title or Position: ADMINISTRATOR
Credential:
Phone: 252-522-4869