Provider Demographics
NPI:1902963499
Name:COUNTRY LIVING GUEST HOME, INC.
Entity Type:Organization
Organization Name:COUNTRY LIVING GUEST HOME, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:HARDISON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:252-402-7823
Mailing Address - Street 1:3134 MARKET STREET EXT
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27889-8127
Mailing Address - Country:US
Mailing Address - Phone:252-975-3741
Mailing Address - Fax:
Practice Address - Street 1:3134 MARKET STREET EXT
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:NC
Practice Address - Zip Code:27889-8127
Practice Address - Country:US
Practice Address - Phone:252-975-3741
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-007-043323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7805415Medicaid