Provider Demographics
NPI:1033651070
Name:DEREK'S PLACE
Entity Type:Organization
Organization Name:DEREK'S PLACE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:HAIRSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-671-3046
Mailing Address - Street 1:150 SECRET GARDEN LN
Mailing Address - Street 2:APT 1
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27104-4721
Mailing Address - Country:US
Mailing Address - Phone:336-671-3046
Mailing Address - Fax:
Practice Address - Street 1:150 SECRET GARDEN LN
Practice Address - Street 2:APT 1
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27104-4721
Practice Address - Country:US
Practice Address - Phone:336-671-3046
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-08
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child