Provider Demographics
NPI:1578628574
Name:LANE HOME
Entity Type:Organization
Organization Name:LANE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SUE
Authorized Official - Middle Name:BATTEN
Authorized Official - Last Name:LANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-965-8407
Mailing Address - Street 1:3620 LIZZIE MILL RD
Mailing Address - Street 2:
Mailing Address - City:SELMA
Mailing Address - State:NC
Mailing Address - Zip Code:27576-8603
Mailing Address - Country:US
Mailing Address - Phone:919-965-8407
Mailing Address - Fax:919-965-8409
Practice Address - Street 1:3620 LIZZIE MILL RD
Practice Address - Street 2:
Practice Address - City:SELMA
Practice Address - State:NC
Practice Address - Zip Code:27576-8603
Practice Address - Country:US
Practice Address - Phone:919-965-8407
Practice Address - Fax:919-965-8409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-051-048322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6603522Medicaid