Provider Demographics
NPI:1437350048
Name:WOODED ACRES #4
Entity Type:Organization
Organization Name:WOODED ACRES #4
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:E
Authorized Official - Last Name:HARDISON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:252-946-6245
Mailing Address - Street 1:3650 CHERRY RD
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27889-7267
Mailing Address - Country:US
Mailing Address - Phone:252-946-1838
Mailing Address - Fax:252-946-6245
Practice Address - Street 1:3650 CHERRY RD
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:NC
Practice Address - Zip Code:27889-7267
Practice Address - Country:US
Practice Address - Phone:252-946-1838
Practice Address - Fax:252-946-6245
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WOODED ACRES GUEST HOME, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-30
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL007056320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7805671Medicaid