Provider Demographics
NPI:1437167798
Name:ALLEGHANY COUNTY GROUP HOMES, INC
Entity Type:Organization
Organization Name:ALLEGHANY COUNTY GROUP HOMES, INC
Other - Org Name:SAMUAL C. EVANS JR GROUP HOME
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DARLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:DOUGLAS
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:336-372-5671
Mailing Address - Street 1:53 ESTEP STREET
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:NC
Mailing Address - Zip Code:28675
Mailing Address - Country:US
Mailing Address - Phone:336-372-5671
Mailing Address - Fax:336-372-5672
Practice Address - Street 1:53 ESTEP STREET
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:NC
Practice Address - Zip Code:28675
Practice Address - Country:US
Practice Address - Phone:336-372-5671
Practice Address - Fax:336-372-5672
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ALLEGHANY COUNTY GROUP HOMES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-03
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
NCMHL003007320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7801839Medicaid