MEDICARE: DEVEREUX RESIDENTIAL SERVICES

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	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1730590035
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEVEREUX RESIDENTIAL SERVICES

Provider Business Mailing Address
First Line	:	201 W MAIN ST
Second Line	:	STE 202A
City	:	DURHAM
State	:	NC
Zip	:	27701-3228
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	103 SETTLERS MILL LN
Second Line	:
City	:	DURHAM
State	:	NC
Zip	:	27713-8541
Country	:	US
Telephone Number	:	919-680-2749
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	JENNIFER WILLIAMS
Credential	:
Telephone Number	:	919-680-2749

Provider Enumeration Date	:	05/08/2014
Last Update Date	:	05/08/2014

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