Provider Demographics
NPI:1154471381
Name:WALLBROWN HOME INC.
Entity Type:Organization
Organization Name:WALLBROWN HOME INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:HENRY
Authorized Official - Last Name:WALLBROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-845-3553
Mailing Address - Street 1:949 N SHORE DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHPORT
Mailing Address - State:NC
Mailing Address - Zip Code:28461-9578
Mailing Address - Country:US
Mailing Address - Phone:910-845-3553
Mailing Address - Fax:910-845-3607
Practice Address - Street 1:949 N SHORE DR
Practice Address - Street 2:
Practice Address - City:SOUTHPORT
Practice Address - State:NC
Practice Address - Zip Code:28461-9578
Practice Address - Country:US
Practice Address - Phone:910-845-3553
Practice Address - Fax:910-845-3607
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL 010 020251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3409239Medicaid