Provider Demographics
NPI:1093017238
Name:MAKING A DIFFERENCE GROUPHOME
Entity Type:Organization
Organization Name:MAKING A DIFFERENCE GROUPHOME
Other - Org Name:MAKING A DIFFERENCE GROUPHOME
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MORRIS
Authorized Official - Suffix:JR
Authorized Official - Credentials:BS,QP
Authorized Official - Phone:252-469-5264
Mailing Address - Street 1:1820 BEDFORD RD
Mailing Address - Street 2:1820 BEDFORD ROAD
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27801-6303
Mailing Address - Country:US
Mailing Address - Phone:252-469-5264
Mailing Address - Fax:
Practice Address - Street 1:1820 BEDFORD RD
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27801-6303
Practice Address - Country:US
Practice Address - Phone:252-469-5264
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-19
Last Update Date:2010-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL033090320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities