Provider Demographics
NPI:1609957869
Name:QUAD COUNTY GROUP HOMES FOR EMOTIONALLY DISTURBED CHILDREN, INC.
Entity Type:Organization
Organization Name:QUAD COUNTY GROUP HOMES FOR EMOTIONALLY DISTURBED CHILDREN, INC.
Other - Org Name:SERENDIPITY HOUSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:P.
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:HARTWIG
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:336-591-7234
Mailing Address - Street 1:PO BOX 508
Mailing Address - Street 2:
Mailing Address - City:WALNUT COVE
Mailing Address - State:NC
Mailing Address - Zip Code:27052-0508
Mailing Address - Country:US
Mailing Address - Phone:336-591-7234
Mailing Address - Fax:336-591-8230
Practice Address - Street 1:664 SPRING ST
Practice Address - Street 2:
Practice Address - City:WALNUT COVE
Practice Address - State:NC
Practice Address - Zip Code:27052-6879
Practice Address - Country:US
Practice Address - Phone:336-591-7234
Practice Address - Fax:336-591-8230
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-085-002323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6603055Medicaid