MEDICARE: DIYAH'S HOME, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility	MHL-043-056	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1265533053
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIYAH'S HOME, INC

Provider Business Mailing Address
First Line	:	PO BOX 2744
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28302-2744
Country	:	US
Telephone Number	:	910-497-8599
Fax Number	:	910-436-5928

Provider Business Practice Location Address
First Line	:	10691 NC HIGHWAY 210 S
Second Line	:
City	:	SPRING LAKE
State	:	NC
Zip	:	28390-8049
Country	:	US
Telephone Number	:	910-497-8599
Fax Number	:	910-436-5928

Authorized Official
Title or Position	:	DIRECTOR/OWNER
Name	:	DAVID HAQQ
Credential	:
Telephone Number	:	910-978-8599

Provider Enumeration Date	:	09/26/2006
Last Update Date	:	08/11/2008

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Directions to “DIYAH'S HOME, INC ” Practice Location

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