Healthcare Provider Details

I. General information

NPI: 1184649915
Provider Name (Legal Business Name): DIYAH'S HOME INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

295 APPALOOSA DR
SPRING LAKE NC
28390-8503
US

IV. Provider business mailing address

295 APPALOOSA DR
SPRING LAKE NC
28390-8503
US

V. Phone/Fax

Practice location:
  • Phone: 910-497-8599
  • Fax: 910-436-5928
Mailing address:
  • Phone: 910-497-8599
  • Fax: 910-436-5928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License NumberMHL-026-583
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License NumberMHL-043-045
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License NumberMHL-043-056
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier6603270
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer
# 2
Identifier6603854
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer
# 3
Identifier6603538
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

Name: MR. DAVID OMAR HAQQ
Title or Position: DIRECTOR
Credential: MA
Phone: 910-978-8599