Provider Demographics
NPI:1225428634
Name:FOKUS RESIDENTIAL SERVICES, LLC
Entity Type:Organization
Organization Name:FOKUS RESIDENTIAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:DERRICK
Authorized Official - Last Name:HAITH
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:336-675-4713
Mailing Address - Street 1:3116 JUNIPER DR
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27215-7934
Mailing Address - Country:US
Mailing Address - Phone:336-270-6004
Mailing Address - Fax:
Practice Address - Street 1:411 TILLMAN ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27217-2358
Practice Address - Country:US
Practice Address - Phone:336-350-8420
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-23
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC001-235320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness