Provider Demographics
NPI:1558428045
Name:COUNTRY LIVING GUEST HOME, INC.
Entity Type:Organization
Organization Name:COUNTRY LIVING GUEST HOME, INC.
Other - Org Name:COUNTRY LIVING GUEST HOME #2
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:KELLIE
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:HARDISON
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LCSW
Authorized Official - Phone:252-975-3741
Mailing Address - Street 1:217 EAST 9TH STREET
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27889-8126
Mailing Address - Country:US
Mailing Address - Phone:252-975-3741
Mailing Address - Fax:252-975-3044
Practice Address - Street 1:3052 MARKET STREET EXTENSION
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:NC
Practice Address - Zip Code:27889-8126
Practice Address - Country:US
Practice Address - Phone:252-975-3741
Practice Address - Fax:252-975-3044
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COUNTRY LIVING GUEST HOME, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-03
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No251S00000XAgenciesCommunity/Behavioral Health
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7804660Medicaid