Provider Demographics
NPI:1578743795
Name:BEROS ENTERPRISE LLC
Entity Type:Organization
Organization Name:BEROS ENTERPRISE LLC
Other - Org Name:EBENEZER HOUSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HABTECHICAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:BEVERLIE
Authorized Official - Middle Name:ROSE
Authorized Official - Last Name:GRIZZLE
Authorized Official - Suffix:
Authorized Official - Credentials:DIRECT OWNER
Authorized Official - Phone:336-491-7190
Mailing Address - Street 1:5331 STIGALL RD
Mailing Address - Street 2:
Mailing Address - City:KERNERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27284-7673
Mailing Address - Country:US
Mailing Address - Phone:336-491-7190
Mailing Address - Fax:336-510-7490
Practice Address - Street 1:5331 STIGALL RD
Practice Address - Street 2:
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-7673
Practice Address - Country:US
Practice Address - Phone:336-491-7190
Practice Address - Fax:336-510-7490
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BEROS ENTERPRISE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-05
Last Update Date:2009-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-034-218322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children