Healthcare Provider Details

I. General information

NPI: 1053457523
Provider Name (Legal Business Name): WOODED ACRES GUEST HOME INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 07/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3650 CHERRY ROAD
WASHINGTON NC
27889-7268
US

IV. Provider business mailing address

3650 CHERRY ROAD
WASHINGTON NC
27889-7268
US

V. Phone/Fax

Practice location:
  • Phone: 252-946-1838
  • Fax:
Mailing address:
  • Phone: 252-946-1838
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberMHL-007-056
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License NumberMHL-007-056
License Number StateNC

VIII. Authorized Official

Name: MR. JAMES E HARDISON
Title or Position: OWNER
Credential:
Phone: 252-946-6245