=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851589659
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EVANGELISTIC DELIVERANCE CENTER ADULT GROUP HOME
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/07/2007
-----------------------------------------------------
Last Update Date | 10/07/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1302 SAINT ANDREW ST
-----------------------------------------------------
City | TARBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27886-3032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-823-3699
-----------------------------------------------------
Fax | 252-641-1681
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1302 SAINT ANDREW ST
-----------------------------------------------------
City | TARBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27886-3032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-823-3699
-----------------------------------------------------
Fax | 252-641-1681
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/OPERATOR/ADMINISTRATOR
-----------------------------------------------------
Name | MRS. PATRICIA WILLIAMS DICKENS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 252-823-3699
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 315P00000X
-----------------------------------------------------
Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------