Provider Demographics
NPI:1003353475
Name:EASON COURT GROUP HOME LLC #2
Entity Type:Organization
Organization Name:EASON COURT GROUP HOME LLC #2
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SONJA
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:571-288-4144
Mailing Address - Street 1:PO BOX 759
Mailing Address - Street 2:
Mailing Address - City:YOUNGSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27596-0759
Mailing Address - Country:US
Mailing Address - Phone:919-556-5355
Mailing Address - Fax:866-285-8824
Practice Address - Street 1:124 GREGORY MNR
Practice Address - Street 2:
Practice Address - City:YOUNGSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27596-9614
Practice Address - Country:US
Practice Address - Phone:919-556-5355
Practice Address - Fax:866-285-8824
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-24
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL 035 050320800000X
NCMHL 035 029320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7804575Medicaid