Provider Demographics
NPI:1063843274
Name:EVANS WALSTON HOME LLC
Entity Type:Organization
Organization Name:EVANS WALSTON HOME LLC
Other - Org Name:EVANS WALSTON HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:GLENDA
Authorized Official - Middle Name:JUDD
Authorized Official - Last Name:EVANS WALSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-552-1312
Mailing Address - Street 1:808 HAWKS VIEW CT
Mailing Address - Street 2:
Mailing Address - City:FUQUAY VARINA
Mailing Address - State:NC
Mailing Address - Zip Code:27526-6642
Mailing Address - Country:US
Mailing Address - Phone:919-552-1312
Mailing Address - Fax:
Practice Address - Street 1:808 HAWKS VIEW CT
Practice Address - Street 2:
Practice Address - City:FUQUAY VARINA
Practice Address - State:NC
Practice Address - Zip Code:27526-6642
Practice Address - Country:US
Practice Address - Phone:919-552-1312
Practice Address - Fax:919-552-1312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-13
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL 092248320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities