Healthcare Provider Details

I. General information

NPI: 1700114816
Provider Name (Legal Business Name): KEAIRA'S HOUSE ADULT GROUP HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2009
Last Update Date: 12/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

836 LINCOLN DR
ROCKY MOUNT NC
27801-7456
US

IV. Provider business mailing address

2828 BERKLEY DR
ROCKY MOUNT NC
27803-1312
US

V. Phone/Fax

Practice location:
  • Phone: 252-446-8162
  • Fax: 252-446-8162
Mailing address:
  • Phone: 252-446-8162
  • Fax: 252-446-8162

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License NumberMHL-033-067
License Number StateNC

VIII. Authorized Official

Name: KEITH EVANS
Title or Position: OWNER
Credential:
Phone: 252-446-8162