Provider Demographics
NPI:1245374545
Name:THE DURHAM FAMILY GROUP HOME 'LODGE STREET HOUSE'
Entity type:Organization
Organization Name:THE DURHAM FAMILY GROUP HOME 'LODGE STREET HOUSE'
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:COX
Authorized Official - Last Name:DURHAM
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:919-730-7405
Mailing Address - Street 1:203 LODGE ST
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-2339
Mailing Address - Country:US
Mailing Address - Phone:919-682-5375
Mailing Address - Fax:919-682-5375
Practice Address - Street 1:203 LODGE ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-2339
Practice Address - Country:US
Practice Address - Phone:919-682-5375
Practice Address - Fax:919-682-5375
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-19
Last Update Date:2007-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL0323933104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness