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General NPI Number Information
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NPI Number | 1902963499
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Entity Type | Organization
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Legal Business Name | COUNTRY LIVING GUEST HOME, INC.
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Dates
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Enumeration Date | 01/03/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 3134 MARKET STREET EXT
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City | WASHINGTON
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State | NC
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Zip | 27889-8127
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Country | US
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Telephone | 252-975-3741
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Fax |
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Provider Business Mailing Address
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Address Line | 3134 MARKET STREET EXT
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City | WASHINGTON
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State | NC
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Zip | 27889-8127
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Country | US
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Telephone | 252-975-3741
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MR. TIM HARDISON
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Credential | R.N.
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Telephone | 252-402-7823
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 323P00000X
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Taxonomy Name | Psychiatric Residential Treatment Facility
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License Number | MHL-007-043
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License Number State | NC
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