Provider Demographics
NPI:1376689117
Name:KEEP HOPE ALIVE, LLC.
Entity Type:Organization
Organization Name:KEEP HOPE ALIVE, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:D
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-353-8003
Mailing Address - Street 1:PO BOX 30557
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27833-0557
Mailing Address - Country:US
Mailing Address - Phone:252-353-8003
Mailing Address - Fax:252-353-9912
Practice Address - Street 1:3219 LANDMARK ST
Practice Address - Street 2:SUITE 6
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-7688
Practice Address - Country:US
Practice Address - Phone:252-353-8003
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2015-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-074-139322D00000X
NCMHL-074-140322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8301166BMedicaid
NC3409645Medicaid
NC6603981Medicaid
NC6603982Medicaid