Provider Demographics
NPI:1780295055
Name:QUEENS GROUP HOME
Entity type:Organization
Organization Name:QUEENS GROUP HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:PROF
Authorized Official - First Name:EKELEKAMCHUKWU
Authorized Official - Middle Name:ALPHONSUS
Authorized Official - Last Name:NGWADOM
Authorized Official - Suffix:
Authorized Official - Credentials:LCMHC
Authorized Official - Phone:919-247-2312
Mailing Address - Street 1:295 ADAMS POINT DR
Mailing Address - Street 2:
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529-6507
Mailing Address - Country:US
Mailing Address - Phone:919-247-2312
Mailing Address - Fax:919-329-7640
Practice Address - Street 1:601 EASTERN AVE
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27801-5856
Practice Address - Country:US
Practice Address - Phone:919-247-2312
Practice Address - Fax:919-329-7640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-11
Last Update Date:2023-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health