Provider Demographics
NPI:1114466893
Name:WALTER B JONES CENTER LAKESIDE PSYCHIATRIC HOSPITAL
Entity Type:Organization
Organization Name:WALTER B JONES CENTER LAKESIDE PSYCHIATRIC HOSPITAL
Other - Org Name:WALTER B JONES ALCOHOL AND DRUG ABUSE TREATMENT CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DEPUTY SECRETARY FBBHDD SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:BURKES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-855-4700
Mailing Address - Street 1:2577 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-7813
Mailing Address - Country:US
Mailing Address - Phone:252-707-5091
Mailing Address - Fax:252-830-8585
Practice Address - Street 1:2577 W 5TH ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834
Practice Address - Country:US
Practice Address - Phone:252-707-5091
Practice Address - Fax:252-830-8585
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-15
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC283Q00000X, 324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility