Provider Demographics
NPI:1083763940
Name:THE PICKETT HOUSE FAMILY CARE HOME
Entity Type:Organization
Organization Name:THE PICKETT HOUSE FAMILY CARE HOME
Other - Org Name:TCHS DAY ACTIVITY PROGRAM
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CORNELL
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-403-9644
Mailing Address - Street 1:3811 PICKETT RD
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705-5331
Mailing Address - Country:US
Mailing Address - Phone:919-403-9644
Mailing Address - Fax:919-489-8489
Practice Address - Street 1:1913 LAMAR ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-3310
Practice Address - Country:US
Practice Address - Phone:919-403-9644
Practice Address - Fax:919-489-8489
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-032-376251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3408619Medicaid