Provider Demographics
NPI:1447390042
Name:LIVING WATERS GROUP HOME
Entity Type:Organization
Organization Name:LIVING WATERS GROUP HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RESIDENTIAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:EALY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-717-6127
Mailing Address - Street 1:8419 CARTMAN DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-8419
Mailing Address - Country:US
Mailing Address - Phone:910-487-2630
Mailing Address - Fax:
Practice Address - Street 1:1609 SWEETGUM CIR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-2707
Practice Address - Country:US
Practice Address - Phone:910-867-3279
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL 026-796322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6603850Medicaid