Healthcare Provider Details

I. General information

NPI: 1912064064
Provider Name (Legal Business Name): COUNTRY LIVING GUEST HOME, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/01/2007
Last Update Date: 06/03/2020
Certification Date: 06/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3094 MARKET STREET EXTENSION
WASHINGTON NC
27889-8126
US

IV. Provider business mailing address

217 EAST 9TH STREET
WASHINGTON NC
27889-8126
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 TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: ANGELA CARROW HARDISON
Title or Position: OWNER
Credential:
Phone: 252-975-3741