Provider Demographics
NPI:1063638328
Name:OUTREACH HOME #1
Entity Type:Organization
Organization Name:OUTREACH HOME #1
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOY
Authorized Official - Middle Name:N
Authorized Official - Last Name:OKEKE
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:919-641-0162
Mailing Address - Street 1:305 SHALIMAR DR
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-7571
Mailing Address - Country:US
Mailing Address - Phone:919-544-1033
Mailing Address - Fax:
Practice Address - Street 1:2826 S ROXBORO ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-4039
Practice Address - Country:US
Practice Address - Phone:919-401-8352
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL032299320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7804843Medicaid