Provider Demographics
NPI:1003197609
Name:RESIDENTIAL SERVICES AT REVERE, LLC
Entity Type:Organization
Organization Name:RESIDENTIAL SERVICES AT REVERE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:PARKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-452-8903
Mailing Address - Street 1:4511 NC HIGHWAY 86 N
Mailing Address - Street 2:
Mailing Address - City:HILLSBOROUGH
Mailing Address - State:NC
Mailing Address - Zip Code:27278-9250
Mailing Address - Country:US
Mailing Address - Phone:919-452-8903
Mailing Address - Fax:
Practice Address - Street 1:516A REVERE RD
Practice Address - Street 2:
Practice Address - City:HILLSBOROUGH
Practice Address - State:NC
Practice Address - Zip Code:27278
Practice Address - Country:US
Practice Address - Phone:919-241-4474
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-09
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC068151320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities