Healthcare Provider Details

I. General information

NPI: 1770293763
Provider Name (Legal Business Name): COUNTRY LIVING GUEST HOME, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2022
Last Update Date: 01/26/2023
Certification Date: 01/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3680 CHERRY ROAD
WASHINGTON NC
27889
US

IV. Provider business mailing address

217 EAST 9TH STREET
WASHINGTON NC
27889
US

V. Phone/Fax

Practice location:
  • Phone: 252-975-3741
  • Fax: 252-975-3044
Mailing address:
  • Phone: 252-975-3741
  • Fax: 252-975-3044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name: MISS KELLIE MICHELLE HARDISON
Title or Position: ADMINISTRATOR
Credential: MSW, LCSW, QP, ADMIR
Phone: 252-975-3741